Annals for Hospitalists - 20 March 2018 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-20 David H. Wesorick, Vineet Chopra
Inpatient Notes Patient Experience as a Health Care Value Domain in Hospitals —Patrick P. Kneeland, MD, and Marisha Burden, MD Is it really possible to accurately measure what patients think and feel while they are in the hospital? And, can those data guide quality improvement initiatives in the hospital? This month's Inpatient Notes summarizes what every hospitalist should know about the emerging concept of “patient experience.” Highlights of Recent Articles From Annals of Internal Medicine In the Clinic: Palliative Care Ann Intern Med. 2018;168:ITC33-ITC48. doi:10.7326/AITC201803060 This recent In the Clinic article provides a broad overview of palliative care. Key points for hospitalists include: Severe pain should be treated with opioid medications, starting with short-acting medications, then titrating the dose and adding long-acting agents as needed. The authors offer a recommended approach to dosing in the Box: Calculating Short- and Long-Acting Opioid Doses. Neuropathic pain may respond to gabapentin, pregabalin, or certain antidepressants. Dyspnea can be successfully managed with nonpharmacologic techniques (e.g., breathing training, gait aids, neuroelectrical muscle stimulation, and chest wall vibration). Low-dose morphine (10-20 mg/d) is considered the gold standard pharmacologic treatment for dyspnea. Other opioids may also be considered. Depression is not a “normal” response to severe illness, and treatment with selective serotonin reuptake inhibitors is often appropriate. In some cases, other agents may have additional beneficial effects (e.g., mirtazapine may increase appetite and improve sleep; tricyclics, duloxetine, and venlafaxine may improve neuropathic symptoms). Opioid Analgesic Use and Risk for Invasive Pneumococcal Diseases: A Nested Case–Control Study Ann Intern Med. 2018;168:396-404. Published 13 February 2018. doi:10.7326/M17-1907 This case–control study used a Medicaid infection surveillance system in Tennessee to identify 1233 cases of invasive pneumococcal disease (IPD) and 24 399 matched controls without IPD, comparing opioid exposure between the groups. The study found that patients with IPD had higher odds of using opioids than controls (odds ratio, 1.62 [95% CI, 1.36 to 1.92]). Key points for hospitalists include: This study identifies opioid use as a novel risk factor for IPD, corroborating other evidence that opioid drugs are associated with an increased risk for infection. The association was strongest for opioids that are long-acting, are potent, or are used in high doses (50-90 morphine milligram equivalents/d). An editorial notes that, while this observational study cannot confirm causation, the efforts made to limit confounding, and concordant results seen in 2 other studies, make the conclusions plausible. Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke: A Systematic Review and Meta-analysis Percutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysis Ann Intern Med. 2018;168:335-342. Published 9 January 2018. doi:10.7326/M17-2679 Ann Intern Med. 2018;168:343-350. Published 9 January 2018. doi:10.7326/M17-3033 These meta-analyses were performed in response to the publication of 2 new randomized controlled trials (RCTs). Each of these meta-analyses examined data from the same 4 RCTs. In all of the included trials, patients experienced cryptogenic stroke, and were found to have patent foramen ovale (PFO). The conclusions of both reviews were similar: Patients treated with mechanical closure of PFO were found to have an approximately 3% reduction in the absolute risk for recurrent stoke, but there was also an increase in the occurrence of atrial fibrillation/flutter in the closure group. Key points for hospitalists include: These meta-analyses, which include 2 new RCTs, show significantly lower rates of recurrent stroke after mechanical closure of PFO in patients presenting with cryptogenic stroke. Even with this new evidence, it is difficult to accurately estimate the risk–benefit ratio for this procedure, because baseline rates of recurrent stroke are low, and the frequency of adverse events from the procedure is not well-defined. An editorial suggests that these meta-analyses may lead to a shift toward more PFO closures in patients with cryptogenic stroke, but the optimal selection criteria for the procedure are not discussed. Risk for Arterial and Venous Thrombosis in Patients With Myeloproliferative Neoplasms: A Population-Based Cohort Study Ann Intern Med. 2018;168:317-325. Published 16 January 2018. doi:10.7326/M17-0028 This cohort study matched 9427 patients with myeloproliferative neoplasms (MPN) to 35 820 controls to assess the risk for thrombosis in patients with these diseases (including polycythemia vera, essential thrombocythemia, and primary myelofibrosis). Patients with MPN were found to have significantly higher risk for thrombosis, especially within 30 days before or after diagnosis, during which time the odds ratio for venous thrombosis was 29.5. The hazard ratio for venous thrombosis at 3 months after diagnosis was 9.7, despite being only 3.2 at 5 years after diagnosis. Ratios for arterial thrombosis were 3 and 1.5, respectively. Key points for hospitalists include: This study confirms that the risk for thrombotic disease for patients with MPN is significantly increased. The increase in risk is especially notable in patients in the study's youngest (18 to 59 years) age group. The risk seems to be highest around the time of diagnosis, decreasing thereafter (probably as a result of treatment) but remaining higher than in controls for the duration of follow-up. An editorial suggests that this new information should result in a renewed interest in modifying traditional thromboembolic risk factors in these patients, and consideration of combinations of anticoagulant, antiplatelet, and anti-inflammatory treatments. The Latest Highlights From ACP Journal Club In patient with atrial fibrillation and stage 3 chronic kidney disease (CKD), do direct oral anticoagulants (DOACs) have an advantage over warfarin? Review: DOACs reduce intracranial hemorrhage more than warfarin in AF with CKD Ann Intern Med. 2017;168:JC18. doi:10.7326/ACPJC-2018-168-4-018 This systematic review analyzed 5 RCTs (n = 12 545) comparing outcomes when using a DOAC versus warfarin for stroke prophylaxis in patients with stage 3 or 4 CKD (97% of patients were stage 3). Although rates of stroke, systemic embolism, and major bleeding were similar between groups, rates of intracranial hemorrhage were significantly lower in the DOAC group (number needed to treat, 130 (95% CI, 80 to 345). Does the use of procalcitonin in the evaluation of acute respiratory infections have an effect on mortality? Review: Procalcitonin-guided starting and stopping of antibiotics in acute respiratory infections reduces mortality Ann Intern Med. 2017;168:JC19. doi:10.7326/ACPJC-2018-168-4-019 This systematic review examined 32 RCTs (n = 10 046) using procalcitonin testing in the evaluation of acute respiratory infections in various settings and concluded that the use of procalcitonin testing algorithms (with adherence ranging from 44% to 100%) resulted in significantly lower antibiotic exposure and lower mortality, but not lower rates of treatment failure. It remains unclear how procalcitonin testing might reduce mortality without reducing the rate of treatment failure. Are sodium bicarbonate infusions and acetylcysteine helpful for preventing adverse effects of angiography? Sodium bicarb vs sodium chloride, and acetylcysteine vs placebo, did not differ for adverse events after angiography Ann Intern Med. 2017;168:JC22. doi:10.7326/ACPJC-2018-168-4-022 This 2 x 2 factorial, randomized placebo-controlled trial allocated 5177 adult patients with an estimated glomerular filtration rate of 15 to 44.9 mL/min/1.73m2 (or 45 to 59.9 mL/min/1.73m2 in patients with diabetes) to 1 of 4 prophylactic interventions prior to a planned angiography study. Patients received sodium bicarbonate, 150 mmol/L IV infusion or normal saline IV infusion, and oral acetylcysteine or placebo. Neither sodium bicarbonate infusion nor acetylcysteine administration had a significant effect on the composite outcome (death, need for dialysis, or creatinine level increase of ≥50%) or the rate of contrast-induced acute kidney injury, and the study was stopped early due to futility. Sign up here to have Annals for Hospitalists delivered to your inbox each month.
Annals for Educators - 20 March 2018 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-20 Darren B. Taichman
Clinical Practice Points Hydroxychloroquine Effectiveness in Reducing Symptoms of Hand Osteoarthritis. A Randomized Trial Osteoarthritis is a common form of arthritis, affecting up to 31% of adults older than 70 years. Effective treatment options are limited and are often associated with adverse effects. This double-blind, placebo-controlled trial examined the efficacy of hydroxychloroquine, a well-established therapy for rheumatoid arthritis, for treatment of osteoarthritis of the hand. Use this study to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners what the clinical characteristics of hand osteoarthritis are. How should they be evaluated? What is the differential diagnosis? Use the information in In the Clinic: Osteoarthritis to help prepare for teaching. What are the risk factors for osteoarthritis? How do your learners treat patients with hand osteoarthritis? Do they use anti-inflammatory drugs? Which ones? Do they work? Do the results of this randomized trial indicate that inflammation is not important in the pathophysiology of hand osteoarthritis? Why or why not? Use the accompanying editorial to help frame your discussion. What are the potential causes of a “negative” trial? What factors need to be considered when evaluating whether negative findings indicate that a therapeutic approach should not be pursued? Antithyroid Drugs and Congenital Malformations. A Nationwide Korean Cohort Study Using a national database of nearly 3 million completed pregnancies, the authors analyzed the risk for congenital malformations associated with different antithyroid drugs used to treat Graves disease during the first trimester. Use this study to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners whether they always review the drugs of pregnant patients to assess whether any are potentially teratogenic. Where do they look? Do your learners know the FDA pregnancy categories? What do they mean? Which categories of drugs do they feel comfortable prescribing to pregnant patients? When should they consult an obstetrician? How do your learners assess whether a drug is safe when a mother is breastfeeding? Ask your learners how hyperthyroidism should be treated during pregnancy. Clinical Guideline Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update This synopsis of the updated Kidney Disease: Improving Global Outcomes guideline, published in 2017, focuses on recommendations for diagnosis and testing for chronic kidney disease–mineral and bone disorder in adults with chronic kidney disease (CKD) and those receiving long-term dialysis. Recommendations address management of phosphate levels, calcium levels, and secondary hyperparathyroidism. Use this guideline to: Ask your learners how CKD is classified. Use the figure in the paper's appendix to review. What mineral and bone disorders are of particular concern among patients with CKD? Who is at risk? Which patients with CKD should undergo dual-energy x-ray absorptiometry (DXA) testing? How should serum phosphate and calcium levels be managed? When and how should phosphate levels be lowered? What dietary recommendations should your learners make to their patients with CKD? When and why should parathyroid hormone levels be measured? How should osteoporosis be treated in patients with CKD? Invite a nephrologist to join your discussion. Humanism and Professionalism On Being a Patient: Lessons From a Year With Breast Cancer: An Academic Physician's Perspective Dr. Trautner reflects on the lessons learned since being diagnosed with breast cancer, observing that she knew them before but has put them more fully into practice since her diagnosis. Use this essay to: Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether the 3 lessons Dr. Trautner describes are “new.” If not, why do we seem to need constant reminders to practice them? Ask a patient (or a few) whether they would be willing or even would enjoy talking with your team about the lessons they have learned since they became ill. Then, ask your patient to tell your team about these lessons during teaching rounds. What did you learn? Can your learners draw inspiration from asking their patients about such lessons? Should we do so regularly? How might such questions be helpful to our patients? Opportunities for Educators Clinical Skills Proposals Wanted for Internal Medicine 2020 Interested in teaching procedural, physical examination, or communication skills? The ACP is accepting proposals for hands-on, interactive workshops that focus on the acquisition or improvement of procedural skills, physical examination skills, and communication skills for Internal Medicine 2020, which will be held in Los Angeles, California, on April 23-25, 2020. To submit a proposal, please complete the Clinical Skills Proposal. The deadline to submit proposals is April 27, 2018. MKSAP 17 Question 1 A 50-year-old woman is evaluated for slowly worsening joint pain in her fingers for the past 5 years. She notes swelling, morning stiffness lasting 10 minutes, and pain that is worse after housework or typing. She has no other joint pain and otherwise feels well. She reports no fevers, weight loss, rashes, alopecia, oral ulcers, dyspnea, chest pain, or abdominal pain. The patient takes no medications. On physical examination, vital signs are normal. There is squaring, crepitus, and tenderness of the first carpometacarpal joints. Bony enlargement and tenderness over all distal interphalangeal (DIP) joints are present. Limited range of motion of the thumbs and DIP joints is noted. There is no joint warmth, redness, or effusions. The remainder of the joint examination is normal. Which of the following is the most appropriate next step in management? A. Anti–double-stranded DNA antibody testing B. Antinuclear antibody testing C. Radiography of the hands D. Rheumatoid factor testing E. No further testing Correct Answer E. No further testing Educational Objective Clinically diagnose osteoarthritis of the hands. Critique No further testing is necessary for this patient who clinically appears to have hand osteoarthritis. Osteoarthritis is a clinical diagnosis, and the cardinal symptom is pain with activity that is relieved with rest. Affected patients also typically experience morning stiffness that lasts for less than 30 minutes daily. Bony hypertrophy is commonly detected in the fingers, and Heberden and Bouchard nodes may be easily palpated. Osteoarthritis also may cause squaring or boxing of the carpometacarpal joint at the base of the thumb. This patient has no clinical signs or symptoms suggestive of a systemic inflammatory disease and therefore does not require diagnostic testing with antinuclear antibodies (ANA) or anti–double-stranded DNA antibodies. A positive ANA test result has low predictive value when the pretest probability of systemic lupus erythematosus or a related disease is low. Therefore, this test should not be used to screen indiscriminately for the presence of rheumatologic disease. The American College of Rheumatology recommends not testing ANA subserologies such as anti–double-stranded DNA without the combination of a positive ANA and elevated clinical suspicion of autoimmune disease, which is not present in this patient. Radiography is not needed to confirm the diagnosis of osteoarthritis in patients with a history and physical examination compatible with this condition. Clinical examination is more sensitive and specific for the diagnosis of hand osteoarthritis compared with radiography. The key features of rheumatoid arthritis (RA) are swelling and tenderness in and around the joints. Prominent morning stiffness that usually lasts more than 1 hour characterizes early RA. Rheumatoid factor positivity is characteristic of RA, although rheumatoid factor has a low specificity for diagnosis of RA. Rheumatoid factor may be present in healthy persons, especially at older ages. Because this patient has no clinical evidence of RA, testing for rheumatoid factor is unnecessary. Key Point Additional testing such as autoantibody measurements or radiography is unnecessary in patients with clinically diagnosed hand osteoarthritis. Bibliography Hunter DJ. In the clinic. Osteoarthritis. Ann Intern Med. 2007 Aug 7;147(3):ITC8-1-16. MKSAP 17 Question 2 A 32-year-old woman is evaluated during a follow-up visit. She indicates that she and her husband are contemplating pregnancy, and she discontinued her oral contraceptive 2 months ago. Medical history is significant for hypertension, type 2 diabetes mellitus, and severe depression, which is currently in remission. Medications are lisinopril, metformin, atorvastatin, and sertraline. She does not smoke or use alcohol or illicit drugs. A normal Pap smear was obtained 1 year ago, no high-risk behaviors are identified, and her vaccinations are up to date. On physical examination, blood pressure is 114/70 mm Hg. BMI is 24. The remainder of the examination is unremarkable. A urine pregnancy test is negative. Her lisinopril is discontinued, and she is started on a prenatal vitamin with folate. Which of the following medications also needs to be discontinued? A. Atorvastatin B. Metformin C. Sertraline D. No additional changes needed Correct Answer A. Atorvastatin Educational Objective Adjust medications in a woman who may become pregnant. Critique Discontinuation of atorvastatin is indicated in this patient who is planning pregnancy. Statin medications should be avoided in pregnancy due to the potential risk for congenital abnormalities. In patients actively planning pregnancy, dyslipidemia is best managed with diet and lifestyle modification for the duration of the pregnancy. Because the effects of statin use during breastfeeding are not known, their use during nursing should be discouraged. ACE inhibitors and angiotensin receptor blockers are also contraindicated due to potential risk of teratogenicity and should be discontinued in women who are planning pregnancy, as was done in this patient. Her hypertension should be followed and treated, if needed, with another agent known to be safe in pregnancy, such as β-blockers, calcium channel blockers, or methyldopa. Oral antidiabetic agents should be continued in women contemplating pregnancy to maintain control of diabetes mellitus. Metformin is an FDA pregnancy category B medication (no definitive studies in pregnant women but no animal studies showing risk to the fetus) and is a reasonable option for controlling this patient's hyperglycemia before pregnancy. Evidence suggests that metformin and sulfonylureas are acceptable during pregnancy; however, further management decisions are best made through co-management of medical and obstetric issues with a high-risk obstetrician. In the treatment of depression, medication discontinuation may not be appropriate in women with a history of major or recurrent depression. Some selective serotonin reuptake inhibitors (SSRIs), including sertraline and fluoxetine, are FDA pregnancy category C (no definitive studies in pregnant women but evidence of potential harm in animal reproduction studies, although potential benefits may warrant use despite potential risks), and their use must be determined on an individual basis. Such agents may be continued if needed, but the risks and benefits of treatment, taking into account severity of depressive symptoms, stage of gestation, and associated circumstances, should be evaluated by a psychiatrist or high-risk obstetrician. SSRIs should not be stopped precipitously. Because this patient is on a known medication classified as FDA pregnancy category X (atorvastatin), continued treatment with this agent would be inappropriate. Key Point Statins, ACE inhibitors, and angiotensin receptor blockers are teratogenic and should be discontinued in women planning pregnancy. Bibliography Callegari LS, Ma EW, Schwarz EB. Preconception care and reproductive planning in primary care. Med Clin North Am. 2015 May;99(3):663-82. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Editors' Note: Call for Articles on Firearm-Related Harm Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-20
Annals of Internal Medicine is committed to helping to end the public health emergency of firearm-related harm. We are working to do so by publishing high-quality research in this understudied area, as well as influential reviews, commentaries, and position papers. A collection of articles we have published in this area is publicly available at http://annals.org/aim/pages/firearm-related-content. In 2013, President Obama directed federal agencies to mount research programs to better understand gun violence and how to reduce it. The Centers for Disease Control and Prevention (CDC) and the CDC Foundation asked the Institute of Medicine (IOM) and the National Research Council (NRC) to define a research agenda for gun violence. In this issue, Dzau and Leshner discuss the 5 key research domains identified in the resulting IOM/NRC report: characteristics of firearm violence, risk and protective factors, interventions and strategies, the effect of gun safety technology, and the influence of video games and other media (1, 2). Annals editors encourage individuals studying these 5 issues and others related to the health consequences of firearm injury to submit their work. Annals will expedite peer review of all manuscripts related to firearms and health. If the article is accepted for publication, we will quickly publish it online first. Published articles related to firearms and health will be added to the publicly available collection noted earlier. References Institute of Medicine; National Research Council. Priorities for Research to Reduce the Threat of Firearm-Related Violence. Washington, DC: National Academies Pr; 2013. doi:10.17226/18319 Dzau VJ, Leshner AI. Public health research on gun violence: long overdue. Ann Intern Med. [Epub ahead of print 20 March 2018] doi:10.7326/M18-0579
Lost in Translation: Linking Biomedical Research and Clinical Practice at the National Institutes of Health, 1977 to 2013 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-20 Todd M. Olszewski
This article examines the history and effect of the Consensus Development Program (CDP) at the National Institutes of Health (NIH). Introduced at a time when the relationship between the U.S. public and the medical profession was at a nadir, the CDP frequently placed the NIH in the middle of broader debates in medical practice and health policy during the last quarter of the 20th century. Drawing on published and archival sources, this paper sheds light on the challenges associated with collecting, assessing, and communicating evidence to medical professionals and convincing them to act on it in the name of improved health care. Administrators at the NIH sought a middle ground between changing medical practice and respecting professional autonomy, with varying degrees of success. This debate has continued implications today as tensions persist between scientific guidelines and the clinical medicine practiced by physicians and expected by patients.
Public Health Research on Gun Violence: Long Overdue Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-20 Victor J. Dzau, Alan I. Leshner
Gun violence is a defining public health challenge of our time. As the United States grapples with the shooting deaths of 17 people in Parkland, Florida, on 14 February 2018, the medical and public health communities must step up and do our share to prevent such devastation from recurring. Effective public health strategies have reduced such threats as motor vehicle injury, tobacco use, accidental poisonings, and drownings. Effective strategies are built on research to identify patterns of risk, illuminate productive targets for intervention, and assess the effectiveness of interventions. Unfortunately, the United States lacks a comprehensive public health approach to gun violence, due in large part to the absence of federal funding for research on gun violence for more than 2 decades. In 2013, after the tragedy at Sandy Hook Elementary School, President Obama directed federal agencies to mount research programs to improve understanding of the causes of gun violence and interventions to reduce it. As a result, the Centers for Disease Control and Prevention (CDC) asked the Institute of Medicine (IOM) and the National Research Council (NRC) to define a public health research agenda for gun violence. The resulting consensus report, “Priorities for Research to Reduce the Threat of Firearm-Related Violence,” laid out the highest-priority research questions to effect progress in a 3- to 5-year time frame (1). These recommendations remain relevant and may be even more urgent today. Without research, policymakers are flying blind when they propose new laws or policies. A provision in a 1996 omnibus spending bill known as the Dickey Amendment forbade the CDC from using its funds to promote or advocate for gun control. This was interpreted as a prohibition on supporting any research on firearms, and the CDC program was dismantled. As a result, we lack even the most basic information about the prevalence and safety of firearms in the United States, as well as data on the effectiveness of interventions aimed at reducing the probability of injury and death related to their use. The shooting in Parkland has prompted renewed calls for research, including from members of Congress. The 2013 IOM/NRC report provides an immediately actionable blueprint to advance such an agenda. The report notes that public health research should be integrated with insights from criminal justice and other fields because no single agency or research strategy can provide all of the answers. The proposed research agenda focuses on characteristics of firearm violence, risk and protective factors, interventions and strategies, the effects of gun safety technology, and the influence of video games and other media. To develop effective strategies to reduce firearm injury and death, it is important to understand what is and what is not known. We lack good data on the number and types of guns in the United States. We need to understand the scope and nature of gun acquisition, ownership, and use across the U.S. population, especially among groups at risk for perpetrating or experiencing gun violence. To protect civil liberties, these data should be collected anonymously. We also need good data on fatal and nonfatal gun incidents, including the proportions that are accidental versus intentional. Factors that may influence the risk posed by guns range from how securely they are stored to complex predictors at the societal, community, situational, and individual levels. At the individual level, risk for perpetration of gun violence coincides with low educational attainment, substance use, and a history of aggression and abuse. In the home, secure storage of guns and accessibility by children are areas of major concern. At the community level, poverty and drug trafficking are known to increase the risk for violence, and at the societal level, cultural norms that promote violence as an acceptable means of conflict resolution may be harmful. These are just a few of the many factors that may relate to risk for gun violence. Only dedicated research can reveal which of these factors, alone or in combination, are the most promising targets for intervention. It is important for research agendas to include evaluations of the effectiveness of interventions to prevent gun violence. Recently, various interventions have been proposed or implemented, such as firearm safety education programs or modifications to the physical environment, including installation of metal detectors. However, we lack conclusive evidence about their effectiveness. Policymakers should be wary of potential unintended consequences of untested “solutions.” Firearm technologies may provide an important opportunity to reduce the public health burden of gun-related injury. Like an airbag in a car or a childproof cap on a pill bottle, the objectives of firearm technologies range from preventing unintentional shootings by young children to reducing suicide. The IOM/NRC report argued that research should examine product safety measures. Specifically, the report proposes research to identify the effects of different technologies designed to reduce firearm injury and death and to explore state and international policy approaches to firearm safety technology for applicability to the United States. Finally, the IOM/NRC report advocated for study of the influence of video games and other media on violence. In more than 50 years of research, no study has focused on real-life firearm violence as a specific outcome of violence in media. As a result, a direct relationship between the two is unproven. If implemented, the public health research agenda proposed in the 2013 IOM/NRC report would provide knowledge to inform our nation's approach to minimizing firearm-related violence and its effects on the health of the U.S. public. Scientific evidence generated by this research would enable the development of sound policies that support the rights and responsibilities central to gun ownership in the United States. It is time to bring the full power of science to bear to deal with this issue of such great concern to our country. We need researchers from different disciplines, including public health, social and behavioral sciences, mental health, and law enforcement, to work together to tackle this problem. That can only happen if we restore the much-needed research funding. It is time to end the counterproductive research freeze. References Institute of Medicine; National Research Council. Priorities for Research to Reduce the Threat of Firearm-Related Violence. Washington, DC: National Academies Pr; 2013. doi:10.17226/18319
Trends in Racial/Ethnic and Nativity Disparities in Cardiovascular Health Among Adults Without Prevalent Cardiovascular Disease in the United States, 1988 to 2014 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-20 Arleen F. Brown, Li-Jung Liang, Stefanie D. Vassar, Jose J. Escarce, Sharon Stein Merkin, Eric Cheng, Adam Richards, Teresa Seeman, W.T. Longstreth
Background: Trends in cardiovascular disparities are poorly understood, even as diversity increases in the United States. Objective: To examine U.S. trends in racial/ethnic and nativity disparities in cardiovascular health. Design: Repeated cross-sectional study. Setting: NHANES (National Health and Nutrition Examination Survey), 1988 to 2014. Participants: Adults aged 25 years or older who did not report cardiovascular disease. Measurements: Racial/ethnic, nativity, and period differences in Life's Simple 7 (LS7) health factors and behaviors (blood pressure, cholesterol, hemoglobin A1c, body mass index, physical activity, diet, and smoking) and optimal composite scores for cardiovascular health (LS7 score ≥10). Results: Rates of optimal cardiovascular health remain below 40% among whites, 25% among Mexican Americans, and 15% among African Americans. Disparities in optimal cardiovascular health between whites and African Americans persisted but decreased over time. In 1988 to 1994, the percentage of African Americans with optimal LS7 scores was 22.8 percentage points (95% CI, 19.3 to 26.4 percentage points) lower than that of whites in persons aged 25 to 44 years and 8.0 percentage points (CI, 6.4 to 9.7 percentage points) lower in those aged 65 years or older. By 2011 to 2014, differences decreased to 10.6 percentage points (CI, 7.4 to 13.9 percentage points) and 3.8 percentage points (CI, 2.5 to 5.0 percentage points), respectively. Disparities in optimal LS7 scores between whites and Mexican Americans were smaller but also decreased. These decreases were due to reductions in optimal cardiovascular health among whites over all age groups and periods: Between 1988 to 1994 and 2011 to 2014, the percentage of whites with optimal cardiovascular health decreased 15.3 percentage points (CI, 11.1 to 19.4 percentage points) for those aged 25 to 44 years and 4.6 percentage points (CI, 2.7 to 6.5 percentage points) for those aged 65 years or older. Limitation: Only whites, African Americans, and Mexican Americans were studied. Conclusion: Cardiovascular health has declined in the United States, racial/ethnic and nativity disparities persist, and decreased disparities seem to be due to worsening cardiovascular health among whites rather than gains among African Americans and Mexican Americans. Multifaceted interventions are needed to address declining population health and persistent health disparities. Primary Funding Source: National Institute of Neurological Disorders and Stroke and National Center for Advancing Translational Science of the National Institutes of Health.
HIV Incidence, HIV Prevalence, and Undiagnosed HIV Infections in Men Who Have Sex With Men, United States Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-20 Sonia Singh, Ruiguang Song, Anna Satcher Johnson, Eugene McCray, H. Irene Hall
Background: HIV infection is a persistent health concern in the United States, and men who have sex with men (MSM) continue to be the most affected population. Objective: To estimate HIV incidence and prevalence and the percentage of undiagnosed HIV infections overall and among MSM. Design: Cross-sectional analysis. Setting: National HIV Surveillance System. Participants: Persons aged 13 years and older with diagnosed HIV infection. Measurements: Data on HIV diagnoses and the first CD4 test result after diagnosis were used to model HIV incidence and prevalence and the percentage of undiagnosed HIV infections from 2008 to 2014 on the basis of a well-characterized CD4 depletion model. Results: Modeled HIV incidence decreased 14.8% overall, from 45 200 infections in 2008 to 38 500 in 2015, and among all transmission risk groups except MSM. The incidence of HIV increased 3.1% (95% CI, 1.6% to 4.5%) per year among Hispanic/Latino MSM (6300 infections in 2008, 7900 in 2015), decreased 2.7% (CI, −3.8% to −1.5%) per year among white MSM (8800 infections in 2008, 7100 in 2015), and remained stable among black MSM at about 10 000 infections. The incidence decreased by 3.0% (CI, −4.2% to −1.8%) per year among MSM aged 13 to 24 years and by 4.7% (CI, −6.2% to −3.1%) per year among those aged 35 to 44 years. Among MSM aged 25 to 34 years, HIV incidence increased 5.7% (CI, 4.4% to 7.0%) per year, from 6900 infections in 2008 to 10 000 in 2015. The percentage of undiagnosed HIV infections was higher among black, Hispanic/Latino, and younger MSM than white and older MSM, respectively. Limitation: Assumptions of the CD4 depletion model and variability of CD4 values. Conclusion: Expansion of HIV screening to reduce undiagnosed infections and increased access to care and treatment to achieve viral suppression are critical to reduce HIV transmission. Access to prevention methods, such as condoms and preexposure prophylaxis, also is needed, particularly among MSM of color and young MSM. Primary Funding Source: None.
Evidence Underpinning the Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Management Bundle (SEP-1): A Systematic Review* Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-20 Dominique J. Pepper, Dharmvir Jaswal, Junfeng Sun, Judith Welsh, Charles Natanson, Peter Q. Eichacker
Background: The Severe Sepsis and Septic Shock Early Management Bundle (SEP-1), the sepsis performance measure introduced in 2015 by the Centers for Medicare & Medicaid Services (CMS), requires the reporting of up to 5 hemodynamic interventions, as many as 141 tasks, and 3 hours to document for a single patient. Purpose: To evaluate whether moderate- or high-level evidence shows that use of the 2015 SEP-1 or its hemodynamic interventions improves survival in adults with sepsis. Data Sources: PubMed, Embase, Scopus, Web of Science, and ClinicalTrials.gov from inception to 28 November 2017 with no language restrictions. Study Selection: Randomized and observational studies of death among adults with sepsis who received versus those who did not receive either the entire SEP-1 bundle or 1 or more SEP-1 hemodynamic interventions, including serial lactate measurements; a fluid infusion of 30 mL/kg of body weight; and assessment of volume status and tissue perfusion with a focused examination, bedside cardiovascular ultrasonography, or fluid responsiveness testing. Data Extraction: Two investigators independently extracted study data and assessed each study's risk of bias; 4 authors rated level of evidence by consensus using CMS criteria published in 2013. High- or moderate-level evidence required studies to have no confounders and low risk of bias. Data Synthesis: Of 56 563 references, 20 studies (18 reports) met inclusion criteria. One single-center observational study reported lower in-hospital mortality after implementation of the SEP-1 bundle. Sixteen studies (2 randomized and 14 observational) reported increased survival with serial lactate measurements or 30-mL/kg fluid infusions. None of the 17 studies were free of confounders or at low risk of bias. In 3 randomized trials, fluid responsiveness testing did not alter survival. Limitation: Few trials, poor-quality and confounded studies, and no studies (with survival outcomes) of the focused examination or bedside cardiovascular ultrasonography. Use of the 2015 version of SEP-1 and 2013 version of CMS evidence criteria, both of which were updated in 2017. Conclusion: No high- or moderate-level evidence shows that SEP-1 or its hemodynamic interventions improve survival in adults with sepsis. Primary Funding Source: National Institutes of Health. (PROSPERO: CRD42016052716)
Fatal Firearm Incidents Before and After Australia's 1996 National Firearms Agreement Banning Semiautomatic Rifles Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-13 Simon Chapman, Michael Stewart, Philip Alpers, Michael Jones
Background: In 1996, after the Port Arthur massacre in Tasmania, the National Firearms Agreement was enacted across Australia. Provisions included uniform gun registration, repudiation of self-defense as a legitimate reason to hold a firearm licence, locked storage, a ban on private gun sales and civilian ownership of semiautomatic rifles and pump-action shotguns, and standardized penalties (1). Two buyback programs and 26 uncompensated amnesties between 1996 and 2015 resulted in the surrender of 1 038 089 illicit firearms (2). An analysis of firearm deaths between 1979 and 2013 showed that 13 mass shootings (homicides in which at least 5 persons died, not including the perpetrator) took place in the 18 years preceding and including the Port Arthur massacre; none has occurred in the 22 years since (3). Many believe that these data indicate that gun law reforms effectively stopped firearm massacres. However, others contend that this interpretation is unwise because of the rarity of these events compared with more common incidents in which fewer than 5 persons died (4). Objective: To test the null hypothesis that the rate of mass shootings remained unchanged after introduction of the National Firearms Agreement. Methods: We modeled the occurrence of mass shootings over time by using a rare events model in which occurrences in nonoverlapping intervals are independent Poisson random variables. Different intervals may have different intensities or rates. The expected value in each interval is the product of the rate and length of the interval. The period before legislation was defined as January 1979 to June 1996 (210 months); the period after legislation was defined as July 1996 to February 2018 (260 months). We considered a constant rate model where the rate of mass shootings was assumed to remain constant over the entire period and a (2-period) changepoint model where the rate differed between these periods. A likelihood ratio test was used to compare the goodness of fit between the models. We calculated the P value associated with the likelihood ratio test by using standard asymptotic theory and through simulation by using a parametric bootstrap method. As a sensitivity analysis, we recomputed the asymptotic P value to determine how it would change if another shooting had taken place in February 2018. An additional sensitivity analysis accounted for possible dependence over time (a mass shooting at 1 time may increase the chances of another in a subsequent short period) by using a test based on scan statistics (5). We obtained (unadjusted) P values for the maximal scan statistic at a range of window sizes between 1 and 18 and obtained a multiplicity-adjusted P value based on the smallest of these. Full details of this test and the simulation are available in the Supplement (available at Annals.org). The range of window sizes used was between 1 and 18 months, suggested by the 2 most significant sizes of 7 and 16 months (Supplement). Results: Under the standard Poisson process model (Figure 1), strong evidence indicates a structural change in 1996. A (conservative, 2-sided) likelihood ratio test for a changepoint in a Poisson process model gives a P value of less than 0.001, which is strong evidence to reject the null hypothesis that the rate of mass shootings did not change after the legislation (Figure 2). Perturbing the data with an extra shooting again gives a P value of less than 0.001. A follow-up goodness-of-fit test designed to detect excessive clumping gives a P value of 0.095, which indicates that the Poisson model is a good fit in this sense; the degree of clumping in the data is not dramatic enough to reject the Poisson process model. Figure 1. Summary of statistics. Reported P values are 2-sided. The constant model assumes that the rate of mass shootings remains constant across the full period; the changepoint model assumes that the rate differs between the before and after periods. LR = likelihood ratio. * January 1979 to June 1996. † July 1996 to February 2018. ‡ Based on 20 million simulations; R code (R Project for Statistical Computing) is provided in the Supplement. Figure 2. Mass shootings. Open circles indicate mass shootings. Top. Occurrences of mass shootings, 1979–1996. Bottom. Estimated rate of mass shootings per year under 2 different models. Our statistical test compared the constant rate and changepoint models, rejecting the former in favor of the latter. The vertical dashed line indicates the change at June 1996. Before 1996, approximately 3 mass shootings took place every 4 years. Had they continued at this rate, approximately 16 incidents (SD, 4) would have been expected since then by February 2018. Discussion: Without a 22-year randomized controlled trial assigning only parts of a national population to live under the National Firearms Agreement, establishing a definitive causal connection between this legislation and the 22-year absence of mass firearm homicides is not possible. However, a standard rare events model provides strong evidence against the hypothesis that this prolonged absence simply reflects a continuation of a preexisting pattern of rare events. References Australasian Police Ministers' Council. National Firearms Agreement. 10 May 1996. Accessed at www.documentcloud.org/documents/2796929-1996-National-Firearms-Agreement.html on 26 February 2018. Alpers P, Rossetti A. Australian firearm amnesty, buyback and destruction totals: official tallies and media-reported numbers, 1987-2015. GunPolicy.org. 3 May 2016. Accessed at www.gunpolicy.org/documents/5337-australia-firearm-amnesty-buyback-and-destruction-totals on 26 February 2018. Chapman S, Alpers P, Jones M. Association between gun law reforms and intentional firearm deaths in Australia, 1979-2013. JAMA. 2016;316:291-9. [PMID: 27332876] doi:10.1001/jama.2016.8752 Kleck G. Did Australia's ban on semi auto firearms really reduce violence? A critique of Chapman et al (2016) study. 12 January 2018. Accessed at www.hoplofobia.info/wp-content/uploads/2015/08/2018-Kleck_Chapman_NFA_comments.pdf on 26 February 2018. Glaz J, Naus J, Wallenstein S. Scan Statistics. New York: Springer-Verlag; 2001.
A Health App to Promote Colorectal Cancer Screening Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-13
What is the problem and what is known about it so far? Many guidelines recommend that adults older than 50 years be screened for colon cancer. Screening tests can help find cancer earlier and decrease the chance of dying from this disease. Unfortunately, as many as 1 in 3 people do not get screened for colon cancer. There are many reasons for this. Doctors may be too busy to discuss all of the options and answer patients' questions. Some patients may be too embarrassed to be screened or may be against it. Different communication methods and ways of ordering these tests are needed to help increase the number of patients who get screened. Why did the researchers do this particular study? To see if an iPad health app that educated patients about different options for colon cancer screening and allowed them to choose the test they wanted would increase the rate of testing. Who was studied? 450 patients (aged 50 to 74 years) who were due for a colon cancer screening test and had an appointment to see their primary care doctor. The study was done in 6 community-based clinics that were associated with a health system in North Carolina. How was the study done? The researchers identified primary care patients who were due for colon cancer screening. Patients who were interested in participating were asked to come to their appointment 45 to 60 minutes early in order to join the study. They were randomly assigned to the colon cancer education group or control group. The colon cancer education group viewed an iPad app that provided information about different screening options, and they were able to “order” either a colonoscopy or a test that looked for blood in the stool. This information was given to the doctor before the visit. Patients also could have the app send them text message or e-mail reminders to help complete the screening test after the visit. The control group watched a video about diet and exercise. They were not given information about colon cancer screening before the visit, and they did not have the option to order their own screening test. Both groups answered questions about what type of colon cancer screening test they preferred, whether they planned to get screened, and whether they had discussed screening with the doctor during the visit. The researchers looked at medical charts and other information to see if patients had a colon cancer screening test within 6 months after the doctor visit. What did the researchers find? Nearly all patients in the colon cancer education group could say which screening test they would like to have. Test ordering and discussions about screening happened more often in the education group than the control group. Researchers found that the colon cancer education group was 2 times as likely to have the test done than the control group (30% vs. 15%). What were the limitations of the study? The study enrolled only patients who spoke English. What are the implications of the study? An iPad health app that allows patients to order tests can help increase rates of colon cancer screening. However, rates were still low (around 30%).
Engaging Survivors of Human Trafficking: Complex Health Care Needs and Scarce Resources Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-13 Abigail M. Judge, Jennifer A. Murphy, Jose Hidalgo, Wendy Macias-Konstantopoulos
Human trafficking, also known as modern-day slavery, is an egregious human rights violation associated with wide-ranging medical and mental health consequences. Because of the extensive health problems related to trafficking, health care providers play a critical role in identifying survivors and engaging them in ongoing care. Although guidelines for recognizing affected patients and a framework for developing response protocols in health care settings have been described, survivors' ongoing engagement in health care services is very challenging. High rates of disengagement, lost contact, premature termination, and attrition are common outcomes. For interventions to be effective in this marginalized population, challenges in engaging survivors in long-term therapeutic primary and mental health care must be better understood and overcome. This article uses the socioecological model of public health to identify barriers to engagement; offers evidence- and practice-based recommendations for overcoming these barriers; and proposes an interdisciplinary call to action for developing more flexible, adaptable models of care.
Effect of a Digital Health Intervention on Receipt of Colorectal Cancer Screening in Vulnerable Patients: A Randomized Controlled Trial Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-13 David P. Miller, Nancy Denizard-Thompson, Kathryn E. Weaver, L. Doug Case, Jennifer L. Troyer, John G. Spangler, Donna Lawler, Michael P. Pignone
Background: Screening for colorectal cancer (CRC) reduces mortality, yet more than one third of age-eligible Americans are unscreened. Objective: To examine the effect of a digital health intervention, Mobile Patient Technology for Health–CRC (mPATH-CRC), on rates of CRC screening. Design: Randomized clinical trial. (ClinicalTrials.gov: NCT02088333) Setting: 6 community-based primary care practices. Participants: 450 patients (223 in the mPATH-CRC group and 227 in usual care) scheduled for a primary care visit and due for routine CRC screening. Intervention: An iPad application that displays a CRC screening decision aid, lets patients order their own screening tests, and sends automated follow-up electronic messages to support patients. Measurements: The primary outcome was chart-verified completion of CRC screening within 24 weeks. Secondary outcomes were ability to state a screening preference, intention to receive screening, screening discussions, and orders for screening tests. All outcome assessors were blinded to randomization. Results: Baseline characteristics were similar between groups; 37% of participants had limited health literacy, and 53% had annual incomes less than $20 000. Screening was completed by 30% of mPATH-CRC participants and 15% of those receiving usual care (logistic regression OR, 2.5 [95% CI, 1.6 to 4.0]). Compared with usual care, more mPATH-CRC participants could state a screening preference, planned to be screened within 6 months, discussed screening with their provider, and had a screening test ordered. Half of mPATH-CRC participants (53%; 118 of 223) “self-ordered” a test via the program. Limitation: Participants were English speakers in a single health care system. Conclusion: A digital health intervention that allows patients to self-order tests can increase CRC screening. Future research should identify methods for implementing similar interventions in clinical care. Primary Funding Source: National Cancer Institute.
Colonoscopy and Colorectal Cancer Mortality in the Veterans Affairs Health Care System: A Case–Control Study Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-13 Charles J. Kahi, Heiko Pohl, Laura J. Myers, Dalia Mobarek, Douglas J. Robertson, Thomas F. Imperiale
Background: Colonoscopy is widely used in the Veterans Affairs (VA) health care system for colorectal cancer (CRC) prevention, but its effect on CRC mortality is unknown. Objective: To determine whether colonoscopy is associated with decreased CRC mortality in veterans and whether its effect differs by anatomical location of CRC. Design: Case–control study. Setting: VA–Medicare administrative data. Participants: Case patients were veterans aged 52 years or older who were diagnosed with CRC between 2002 and 2008 and died of the disease by the end of 2010. Case patients were matched to 4 control patients without prior CRC on the basis of age, sex, and facility. Conditional logistic regression was performed to calculate odds ratios (ORs) for exposure to colonoscopy, with adjustment for race, Charlson Comorbidity Index score, selected chronic conditions, nonsteroidal anti-inflammatory drug use, and family history of CRC. Measurements: Exposure to colonoscopy was determined from 1997 to 6 months before CRC diagnosis in case patients and to a corresponding date in control patients. Subgroup analysis was performed for patients who had undergone screening colonoscopy. Results: A total of 4964 case patients and 19 856 control patients were identified. Case patients were significantly less likely to have undergone any colonoscopy (OR, 0.39 [95% CI, 0.35 to 0.43]). Colonoscopy was associated with reduced mortality for left-sided cancer (OR, 0.28 [CI, 0.24 to 0.32]) and right-sided cancer (OR, 0.54 [CI, 0.47 to 0.63]). The results were similar for patients who had undergone screening colonoscopy (overall OR, 0.30 [CI, 0.24 to 0.38]). Sensitivity analyses that varied the interval between CRC diagnosis and colonoscopy exposure did not affect the primary findings. Limitation: Unmeasured confounding. Conclusion: In this study using national VA–Medicare data, colonoscopy was associated with significant reductions in CRC mortality among veterans and was associated with greater benefit for left-sided cancer than right-sided cancer. Primary Funding Source: U.S. Department of Veterans Affairs.
Hemoglobin A1c Targets for Nonpregnant Adults With Type 2 Diabetes Mellitus Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-06
Who developed these recommendations? The American College of Physicians (ACP) developed these recommendations. The ACP is a professional organization for internal medicine doctors, who specialize in health care for adults. What is the problem and what is known about it so far? Type 2 diabetes is a common disease that makes it difficult for the body to use sugar and store energy from food. Common symptoms include urinating often and increased thirst, but diabetes often has no symptoms. Over time, high blood sugar levels can lead to health problems, including blindness, kidney failure, nerve damage, heart attack, stroke, and the need to amputate certain body parts (such as fingers and toes). Treatment to control blood sugar levels includes eating healthy food, regular exercise, and medicines. Doctors measure sugar with a blood test called hemoglobin A1c (HbA1c) to diagnose and control the disease. Different organizations define good control with different HbA1c levels. The ACP reviewed guidelines for HbA1c targets in nonpregnant adults with type 2 diabetes to develop guidance to help doctors and patients decide what levels to aim for. How did the ACP develop these recommendations? The ACP Clinical Guidelines Committee reviewed 6 guidelines to rate their quality. They used this information to develop recommendations for HbA1c targets that ACP believes would be best for nonpregnant adults with type 2 diabetes. An HbA1c level below 7% can reduce the chances of diabetes complications. However, this level can be difficult to achieve and can be associated with weight gain and life-threatening episodes of low blood sugar. What does the ACP suggest that patients and doctors do? Doctors and patients should work together to create goals for diabetes control. These goals should consider the benefits and harms of diabetes medicines, patient preferences and general health, and costs of treatment. For most patients, HbA1c levels should be between 7% and 8%. Doctors and patients should consider decreasing the dose or stopping diabetes medicines if HbA1c levels fall below 6.5%. If a patient has type 2 diabetes and is not expected to live longer than 10 years, lower HbA1c levels might cause more harm than benefit. These patients include people older than 80 years; people who live in a nursing home; and people who have serious health conditions, such as dementia, cancer, kidney disease, severe chronic obstructive pulmonary disease, or heart failure. Questions you may want to ask your doctor • What is HbA1c, and how often should I have this test? • How do I measure my blood sugar at home and how often? • What HbA1c level is best for me? • What can I do to get my HbA1c to this level? • What is the best diet for me? • How much should I exercise? • What symptoms might mean that my blood sugar is too high or too low? • What should I do if I have symptoms of low blood sugar?
Annals Graphic Medicine - Is This What Depression Looks Like? Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-06 William J. Doan
Palliative Care Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-06 Keith M. Swetz, Arif H. Kamal
Palliative care prioritizes symptom management and quality of life throughout the course of serious illness. Regardless of whether care is inpatient or outpatient, primary or subspecialty, a solid understanding of the basics of effective communication, symptom management, and end-of-life care is crucial. This article reviews these essentials and provides an overview of current evidence to support patient-centered palliative care.
Annals for Educators - 6 March 2018 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-06 Darren B. Taichman
Clinical Practice Points Risk for Arterial and Venous Thrombosis in Patients With Myeloproliferative Neoplasms. A Population-Based Cohort Study Patients with myeloproliferative neoplasms (MPNs) have been reported to be at increased risk for thrombotic events, but no population-based study has estimated this excess risk compared with matched control participants. This study analyzed data on patients reported to the Swedish Cancer Register between 1987 and 2009 to assess risk for arterial and venous thrombosis among those with MPNs compared with matched control participants. Use this study to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners if they can name the 3 major subtypes of MPNs. In what ways do patients with each of these MPNs present? How is each diagnosed? Use the information in the DynaMed Plus sections on polycythemia vera, essential thrombocythemia, and primary myelofibrosis (a benefit of your ACP membership!). What is the relationship between JAK2 and each MPN subtype? The accompanying editorial explains this. What does this study tell us about risk for thrombotic events in patients with MPNs? Look at Figure 3. What change in the risk for venous thrombosis has occurred with time? The authors believe this is likely due to improved management. How are patients with MPNs treated? In addition to the risk for thrombosis, what other complications occur? Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke. A Systematic Review and Meta-analysis Percutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale. A Systematic Review and Meta-analysis These meta-analyses of recent landmark trials examined the benefits and harms of percutaneous closure of patent foramen ovale (PFO) compared with medical therapy alone in patients with cryptogenic stroke. Use these papers to: PFOs are highly prevalent. What are the potential complications? What should the poststroke work-up include? The authors of the second review provide a concise list in their paper's discussion. When should closure of a PFO be considered? What patients were included in the trials used for these meta-analyses (i.e., were they patients with incidentally noted PFOs or those who had experienced 1 or recurrent strokes)? Why does that matter when considering which patients should undergo PFO closure? How is PFO closure accomplished? Invite an interventional cardiologist to join your discussion and to show films of the procedure. What are the potential complications of PFO closure? What more do we need to know? Should these papers alter practice? Use the accompanying editorial to inform your discussion. The Hypertension Guidelines (Again!) Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline The 2017 American College of Cardiology/American Heart Association Hypertension Guideline: A Resource for Practicing Clinicians Hypertension Limbo: Balancing Benefits, Harms, and Patient Preferences Before We Lower the Bar on Blood Pressure The recent American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guideline differs substantially from its predecessor and from the guidelines of other organizations. It is more than 100 pages long and includes 106 recommendations. The guideline developers present a synopsis of the most important changes and recommendations. Here, a commentary discusses why the new guideline is helpful, and the editorialists discuss why they believe it falls short in weighing potential benefits and harms, particularly for adults older than 60 years. Use these papers to: Ask your learners how the updated ACC/AHA guideline differs from the prior version and from guidelines from other organizations, such as the American College of Physicians and the American Academy of Family Physicians. Why are these differences so important? Look at the figures in the guideline synopsis. Do your learners believe they should use home and ambulatory blood pressure measurements more often than they do? What limitations in what is known about the risks and outcomes related to hypertension and its treatment are noted by the editorialists? What are the limitations of the clinical trials on which guidelines are based? Why might these be important? What approach will your learners take to diagnosing patients with and treating hypertension? In the Clinic In the Clinic: Palliative Care Palliative care prioritizes symptom management and quality of life throughout the course of serious illness. Regardless of whether care is inpatient or outpatient, primary or subspecialty, a solid understanding of the basics of effective communication, symptom management, and end-of-life care is crucial. This eminently practical review addresses these essentials and provides an overview of current evidence to support patient-centered palliative care. Use this paper to: Ask your learners what the differences are between palliative care and hospice care. Who is eligible for each? Why might patients' perceptions, misconceptions, and fears of hospice care influence their interest in palliative care? How would your learners discuss this with their patients? Look at the Patient Information sheet at the end. Would this be helpful to your patients? When do your learners consider consultation with a palliative care team? What should they expect from such a consultation? Invite a member of your institution's palliative care service to join your discussion. Do your learners use a systematic approach to evaluating and managing pain? In what ways should the approach differ according to the cause? How should adverse effects of opioids be managed? Are your learners comfortable prescribing narcotics for patients with dyspnea? When is it appropriate? How much? How do your learners ask patients about their goals of care? Are they comfortable doing so? How might the manner in which they pose questions matter? Use Table 4 to help spark discussion. Download the teaching slides, and use the multiple-choice questions to help introduce topics for discussion. Be sure to log on and enter your answers to earn CME and MOC credit for yourself! Humanism and Professionalism On Being a Doctor: Note to an Oncology Fellow Dr. Vettese answers why she discussed hospice care with her patient instead of encouraging palliative chemotherapy and implores her colleague to ask patients what they would be willing to give up to live longer. Use this essay to: Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Why does the author suggest that we ask our patients what they would never give up? How do your learners react to this essay? Is this an issue of “older” versus “younger” doctors? Have your learners ever felt that other physicians have failed to adequately consider a patient's circumstances and desires? Have others ever suggested that your learners have done so? Why do such differences in opinion occur? Are they harmful to patients? Annals Graphic Medicine - Is This What Depression Looks Like? The author/artist imagines what depression looks like inside himself and wonders, “Is this the black dog of depression I've read about?” Use this feature to: Show the graphic to your learners. How do they react? Do the images make them think differently about patients with depression? How? Does it alter their impressions of what is and is not within the control of the patient? Do such graphic depictions help us to foster our sense of empathy in ways that differ from other experiences? Might sharing these images with a patient who has depression be helpful? Might it be hurtful? MKSAP 17 Question A 27-year-old woman is evaluated during a follow-up visit. She was evaluated 3 months previously for symptoms of fatigue of 9 months' duration and a craving for ice. She experiences heavy, irregular menstrual cycles, but has no history of other bleeding. Medications are oral contraceptive pills and daily iron, which were initiated 3 months ago. On physical examination, vital signs are normal; BMI is 31. No splenomegaly is noted. Laboratory studies: 3 Months Ago 2 Months Ago Current Ferritin 6 ng/mL (6 µg/L) 16 ng/mL (16 µg/L) 45 ng/mL (45 µg/L) Hemoglobin 8.7 g/dL (87 g/L) 10.1 g/dL (101 g/L) 13 g/dL (130 g/L) Mean corpuscular volume 71 fL 77 fL 88 fL Platelet count 800,000/µL (800 × 109/L) 790,000/µL (790 × 109/L) 775,000/µL (775 × 109/L) 3 Months Ago 2 Months Ago Current Ferritin 6 ng/mL (6 µg/L) 16 ng/mL (16 µg/L) 45 ng/mL (45 µg/L) Hemoglobin 8.7 g/dL (87 g/L) 10.1 g/dL (101 g/L) 13 g/dL (130 g/L) Mean corpuscular volume 71 fL 77 fL 88 fL Platelet count 800,000/µL (800 × 109/L) 790,000/µL (790 × 109/L) 775,000/µL (775 × 109/L) Which of the following is the most appropriate diagnostic test to perform next? A. BCR-ABL genetic analysis B. JAK2 V617F analysis C. Prothrombin time and activated partial thromboplastin time D. von Willebrand factor antigen Correct Answer B. JAK2 V617F analysis Educational Objective Diagnose essential thrombocythemia. Critique Mutational analysis for JAK2 V617F should be conducted. The patient presented with iron deficiency anemia and thrombocytosis. Thrombocytosis is often associated with iron deficiency anemia, particularly if bleeding is the cause of the anemia. However, when the patient's anemia was corrected with oral iron and oral contraceptive pills for better regulation of menstruation, thrombocytosis persisted, suggesting a disorder in platelet regulation. Iron deficiency is the most common cause of reactive thrombocytosis, which corrects within weeks of correcting the iron deficiency. Infection, inflammation, and malignancy are other causes. With iron deficiency ruled out as a cause and no other causes clinically apparent, essential thrombocythemia (ET) becomes more probable. Her lack of splenomegaly is fairly typical. The JAK2 activating mutation is present in 50% of patients with ET, so a negative result would not exclude the diagnosis, but a positive result supports the diagnosis of a myeloproliferative neoplasm (polycythemia vera, ET, or primary myelofibrosis). BCR-ABL testing, then bone marrow aspiration and biopsy, would be performed if the platelet count remained persistently elevated after correction of serum iron levels with a negative JAK2 mutation status, because myeloproliferative neoplasms other than ET can less commonly elevate the platelet count. In ET, general hypercellularity and megakaryocyte hyperplasia would be seen on the bone marrow examination. Testing the prothrombin and activated partial thromboplastin times would not be the most appropriate choice, because it focuses the diagnosis on a bleeding diathesis rather than thrombocytosis. Similarly, von Willebrand factor antigen testing does not address the patient's persistently elevated platelet count. Key Point A patient with iron deficiency and isolated thrombocytosis that persists after correction of iron deficiency should undergo JAK2 V617F mutational analysis as part of the evaluation for essential thrombocythemia. Bibliography Tefferi A. Polycythemia vera and essential thrombocythemia: 2013 update on diagnosis, risk-stratification, and management. Am J Hematol. 2013 Jun;88(6):507-16. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Correction: Presence of Human Hepegivirus-1 in a Cohort of People Who Inject Drugs Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-06
In a recent letter to the editor (1), in the sentence “The high-throughput sequencing procedure was validated by identifying HHpgV-1 (formerly GB virus C) RNA sequences in approximately 11% of the African samples investigated,” “HHpgV-1” should be “HpgV-1.” This has been corrected. References Candotti D Deng X Li T Laperche S Sauvage V Presence of human hepegivirus-1 in a cohort of people who inject drugs [Letter]. Ann Intern Med 2018 168 158 . CrossRef PubMed
Hemoglobin A1c Targets for Glycemic Control With Pharmacologic Therapy for Nonpregnant Adults With Type 2 Diabetes Mellitus: A Guidance Statement Update From the American College of Physicians Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-06 Amir Qaseem, Timothy J. Wilt, Devan Kansagara, Carrie Horwitch, Michael J. Barry, Mary Ann Forciea
Description: The American College of Physicians developed this guidance statement to guide clinicians in selecting targets for pharmacologic treatment of type 2 diabetes. Methods: The National Guideline Clearinghouse and the Guidelines International Network library were searched (May 2017) for national guidelines, published in English, that addressed hemoglobin A1c (HbA1c) targets for treating type 2 diabetes in nonpregnant outpatient adults. The authors identified guidelines from the National Institute for Health and Care Excellence and the Institute for Clinical Systems Improvement. In addition, 4 commonly used guidelines were reviewed, from the American Association of Clinical Endocrinologists and American College of Endocrinology, the American Diabetes Association, the Scottish Intercollegiate Guidelines Network, and the U.S. Department of Veterans Affairs and Department of Defense. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument was used to evaluate the guidelines. Guidance Statement 1: Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care. Guidance Statement 2: Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes. Guidance Statement 3: Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%. Guidance Statement 4: Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.
Direct-Acting Antiviral Prophylaxis in Kidney Transplantation From Hepatitis C Virus–Infected Donors to Noninfected Recipients: An Open-Label Nonrandomized Trial Ann. Intern. Med. (IF 17.135) Pub Date : 2018-03-06 Christine M. Durand, Mary G. Bowring, Diane M. Brown, Michael A. Chattergoon, Guido Massaccesi, Nichole Bair, Russell Wesson, Ashraf Reyad, Fizza F. Naqvi, Darin Ostrander, Jeremy Sugarman, Dorry L. Segev, Mark Sulkowski, Niraj M. Desai
Background: Given the high mortality rate for patients with end-stage kidney disease receiving dialysis and the efficacy and safety of hepatitis C virus (HCV) treatments, discarded kidneys from HCV-infected donors may be a neglected public health resource. Objective: To determine the tolerability and feasibility of using direct-acting antivirals (DAAs) as prophylaxis before and after kidney transplantation from HCV-infected donors to non–HCV-infected recipients (that is, HCV D+/R− transplantation). Design: Open-label nonrandomized trial. (ClinicalTrials.gov: NCT02781649) Setting: Single center. Participants: 10 HCV D+/R− kidney transplant candidates older than 50 years with no available living donors. Intervention: Transplantation of kidneys from deceased donors aged 13 to 50 years with positive HCV RNA and HCV antibody test results. All recipients received a dose of grazoprevir (GZR), 100 mg, and elbasvir (EBR), 50 mg, immediately before transplantation. Recipients of kidneys from donors with genotype 1 infection continued receiving GZR–EBR for 12 weeks after transplantation; those receiving organs from donors with genotype 2 or 3 infection had sofosbuvir, 400 mg, added to GZR–EBR for 12 weeks of triple therapy. Measurements: The primary safety outcome was the incidence of adverse events related to GZR–EBR treatment. The primary efficacy outcome was the proportion of recipients with an HCV RNA level below the lower limit of quantification 12 weeks after prophylaxis. Results: Among 10 HCV D+/R− transplant recipients, no treatment-related adverse events occurred, and HCV RNA was not detected in any recipient 12 weeks after treatment. Limitation: Nonrandomized study design and a small number of patients. Conclusion: Pre- and posttransplantation HCV treatment was safe and prevented chronic HCV infection in HCV D+/R– kidney transplant recipients. If confirmed in larger studies, this strategy should markedly expand organ options and reduce mortality for kidney transplant candidates without HCV infection. Primary Funding Source: Merck Sharp & Dohme Corp.
Correction: Whole-Exome Sequencing in Adults With Chronic Kidney Disease: A Pilot Study Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-20
The second sentence of the Results section of the abstract in a recent article (1) should read as follows: Among these, loss-of-function mutations were identified in PARN in 2 probands respectively diagnosed with tubulointerstitial fibrosis and chronic kidney disease of unknown cause. This has been corrected. References Lata S Marasa M Li Y Fasel DA Groopman E Jobanputra V et al Whole-exome sequencing in adults with chronic kidney disease. A pilot study, Ann Intern Med 2018 168 100 9 PubMed
Cognitive Behavioral Therapy Versus Education for Chronic Pain Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-27
What is the problem and what is known about it so far? Chronic pain is a common problem that affects many people who have a low income or are members of minority groups. It is difficult to treat. Cognitive behavioral therapy (CBT) is a form of psychotherapy that teaches people how thoughts, feelings, physical sensations (such as pain), and behaviors are connected, as well as coping skills to help them feel better. Although CBT has been shown to be effective in treating pain, low-income patients with pain may have problems getting this therapy. Furthermore, trials of CBT have not been done with patients from low-income communities. Why did the researchers do this particular study? The researchers wanted to compare the effects of CBT, a pain education (EDU) program, and usual care on pain levels in patients who have chronic pain. Who was studied? 290 adults with chronic pain symptoms. Most had an income at or below the poverty level, and about one third had a reading level below fifth grade. Many participants were taking opioids at the beginning of the study. How was the study done? The study participants were randomly assigned to receive CBT, EDU, or usual care. The researchers developed the CBT and EDU programs for adults with limited reading ability. The participants who were assigned to the CBT and EDU programs attended group sessions held once a week for 10 weeks. Participants in all 3 groups answered questionnaires about their pain levels and physical functioning at baseline, 10 weeks, and 6 months. What did the researchers find? After the 10 weeks, participants in the CBT and EDU groups had a greater decrease in their pain levels than those in the usual care group, which did not show much change over time. The EDU group still had improved pain levels at 6 months, but the CBT group did not. Both the CBT and EDU groups showed greater improvement in physical functioning than the usual care group at 10 weeks and at 6 months. What were the limitations of the study? The researchers could not tell whether the CBT or EDU program resulted in a change in the amount of opioids used by the participants. What are the implications of the study? CBT and EDU programs that were simplified for reading ability resulted in improved pain and physical functioning in patients with chronic pain.
Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician: A Position Paper of the American College of Physicians Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-27 Lisa Soleymani Lehmann, Lois Snyder Sulmasy, Sanjay Desai
Much of what is formally taught in medicine is about the knowledge, skills, and behaviors required of a physician, including how to express compassion and respect for patients at the bedside. What is learned, however, includes not only admirable qualities but also behaviors and qualities that are inconsistent with ethics and professionalism. Positive role models may reinforce the character and values the profession seeks to cultivate; negative ones directly contradict classroom lessons and expectations of patients, society, and medical educators. These positive and negative lessons, which are embedded in organizational structure and culture, are the hidden curricula conveyed in medical schools, residency programs, hospitals, and clinics. This position paper from the American College of Physicians focuses on ethics, professionalism, and the hidden curriculum. It provides strategies for revealing what is hidden to foster the development of reflective and resilient lifelong learners who embody professionalism and clinicians who are, and are perceived as, positive role models. Making the hidden visible and the implicit explicit helps to create a culture reflecting medicine's core values.
Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain at Low-Income Clinics: A Randomized Controlled Trial Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-27 Beverly E. Thorn, Joshua C. Eyer, Benjamin P. Van Dyke, Calia A. Torres, John W. Burns, Minjung Kim, Andrea K. Newman, Lisa C. Campbell, Brian Anderson, Phoebe R. Block, Bentley J. Bobrow, Regina Brooks, Toya T. Burton, Jennifer S. Cheavens, Colette M. DeMonte, William D. DeMonte, Crystal S. Edwards, Minjeong Jeong, Mazheruddin M. Mulla, Terence Penn, Laura J. Smith, Deborah H. Tucker
Background: Chronic pain is common and challenging to treat. Although cognitive behavioral therapy (CBT) is efficacious, its benefit in disadvantaged populations is largely unknown. Objective: To evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT01967342) Setting: Community health centers serving low-income patients in Alabama. Patients: Adults (aged 19 to 71 years) with mixed chronic pain. Interventions: CBT and EDU delivered in 10 weekly 90-minute group sessions. Measurements: Self-reported, postintervention pain intensity (primary outcome) and physical function and depression (secondary outcomes). Results: 290 participants were enrolled (70.7% of whom were women, 66.9% minority group members, 72.4% at or below the poverty level, and 35.8% reading below the fifth grade level); 241 (83.1%) participated in posttreatment assessments. Linear mixed models included all randomly assigned participants. Members of the CBT and EDU groups had larger decreases in pain intensity scores between baseline and posttreatment than participants receiving usual care (estimated differences in change scores—CBT: −0.80 [95% CI −1.48 to −0.11]; P = 0.022; EDU: −0.57 [CI, −1.04 to −0.10]; P = 0.018). At 6-month follow-up, treatment gains were not maintained in the CBT group but were still present in the EDU group. With regard to physical function, participants in the CBT and EDU interventions had greater posttreatment improvement than those receiving usual care, and this progress was maintained at 6-month follow-up. Changes in depression (secondary outcome) did not differ between either the CBT or EDU group and the usual care group. Limitations: Participants represented a single health care system. Self-selection bias may have been present. Conclusion: Simplified group CBT and EDU interventions delivered at low-income clinics significantly improved pain and physical function compared with usual care. Primary Funding Source: Patient-Centered Outcomes Research Institute.
Hydroxychloroquine to Reduce Symptoms of Hand Osteoarthritis Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-20
What is the problem and what is known about it so far? Osteoarthritis is a common form of arthritis that affects adults. There are few effective therapies, and many have side effects. Some studies have suggested that low levels of inflammation cause symptoms in osteoarthritis. A few studies have examined hydroxychloroquine—a well-established treatment of rheumatoid arthritis—for patients with inflammatory forms of osteoarthritis. Why did the researchers do this particular study? To determine whether hydroxychloroquine is an effective treatment of osteoarthritis of the hand. Who was studied? 248 adults with hand pain due to osteoarthritis. How was the study done? The participants were randomly assigned to receive either hydroxychloroquine or placebo (sugar pill) for 12 months in addition to usual care for their arthritis. The researchers used questionnaires to measure the participants' pain levels and quality of life. They also did ultrasound studies of the hand joints at baseline and measured the participants' grip strength at baseline, 3 months, 6 months, and 12 months. What did the researchers find? The participants were an average age of 62.7 years, and most were women. They had had symptoms of hand osteoarthritis for about 5 years, and their average pain level was 7 out of 10. After 6 months of treatment, there were no differences between the hydroxychloroquine and placebo groups in terms of pain levels or grip strength. What were the limitations of the study? The study enrolled adults with long-standing osteoarthritis symptoms. If adults with newer symptoms of hand osteoarthritis had been enrolled, the results might have been different. What are the implications of the study? Hydroxychloroquine does not offer any benefit over placebo for treatment of osteoarthritis of the hand.
Annals for Hospitalists - 20 February 2018 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-20 David H. Wesorick, Vineet Chopra
Inpatient Notes Perioperative Medicine—The Past, Present, and Future of Cardiovascular Risk Assessment and Risk Reduction Strategies —Paul J. Grant, MD, and Kim A. Eagle, MD In this month's Inpatient Notes, the authors discuss current strategies to assess and reduce cardiovascular risk for surgical patients while reflecting on past practices and looking forward to future developments. Highlights of Recent Articles From Annals of Internal Medicine In the Clinic: Cellulitis and Soft Tissue Infections Ann Intern Med. 2018;168:ITC17-ITC32. doi:10.7326/AITC201802060 This recent In the Clinic article discusses the prevention, diagnosis, and treatment of a wide range of skin and soft tissue infections. Key points for hospitalists include: For cellulitis, the causative organism can be difficult to isolate, especially when there is no purulent material to culture. Therefore, treatment is usually empirical. As a rule, nonpurulent cellulitis is usually caused by streptococci, and purulent infections are usually caused by staphylococci, including community-associated methicillin-resistant Staphylococcus aureus (MRSA). Empirical antibiotic therapy should cover MRSA if cellulitis is associated with purulence, risk factors for MRSA are present (e.g., a history of MRSA, illicit inhalation or injection drug use, recent antibiotic use or hospitalization, or current hemodialysis or HIV infection), or the patient is severely ill or immunocompromised. Necrotizing skin infections should be treated with emergent surgical debridement and broad spectrum antibiotics, including clindamycin to bind streptococcal toxin. Necrotizing skin infections can be recognized by the presence of several clinical findings, including pain out of proportion to examination findings, induration beyond the area of skin involvement, blisters, mottling, anesthesia, crepitus, necrosis, ecchymosis, systemic toxicity, or organ failure. Although computed tomography has shown some promise in diagnosing necrotizing skin infections, surgical exploration is the gold standard diagnostic test, and surgical consultation should not be delayed to allow for imaging when these infections are suspected. Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery Ann Intern Med. 2018;168:237-244. Published 14 November 2017. doi:10.7326/M17-2341 This study is a non-prespecified subgroup analysis of a previously completed multicenter randomized controlled trial (POISE-2 [PeriOperative ISchemic Evaluation-2] trial). One group of this trial compared aspirin versus placebo in patients having noncardiac surgery, and this analysis examines the subgroup of 470 patients who had received a bare-metal coronary stent within 6 weeks before enrollment or a drug-eluting coronary stent within 1 year before enrollment. In these patients, risk for the primary composite outcome (death or nonfatal myocardial infarction) was reduced in patients randomly assigned to aspirin (hazard ratio, 0.5 [95% CI, 0.26 to 0.95]), driven by a reduction in myocardial infarction rates. There was no statistically significant increase in bleeding events in patients with coronary stents receiving aspirin compared with those receiving placebo. Key points for hospitalists include: Patients with previous percutaneous coronary interventions with coronary stents (who are outside the usual window for dual-antiplatelet therapy) seem to benefit from continuation of aspirin when undergoing noncardiac surgery. Although there was no statistical difference in bleeding risk between patients treated with aspirin or placebo in this stented subgroup, the larger trial (including patients with and without stents) did show an increase in major bleeding with aspirin (hazard ratio, 1.22 [CI, 1.01 to 1.48]). The authors felt that this was a more accurate estimate of bleeding risk. Using this estimate, the authors calculated that the use of perioperative aspirin in 1000 patients with coronary stents would prevent 59 myocardial infarctions and cause 8 major bleeding events. An editorial suggests that the ischemic benefit of continuing perioperative aspirin in patients with coronary stents would be negated only in surgical procedures with a baseline bleeding risk of 26% or more. Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients With Suspected Infection: A Systematic Review and Meta-analysis Ann Intern Med. 2018;168:266-275. Published 6 February 2018. doi:10.7326/M17-2820 In this study, the authors analyzed data from 38 cohort studies (n = 385 333) to calculate the pooled sensitivity and specificity for the outcome of mortality of the quick Sequential Organ Failure Assessment (qSOFA) and the systemic inflammatory response syndrome (SIRS) criteria in patients with suspected infection. The qSOFA was associated with a pooled sensitivity of 60.8% (95% CI, 51.4% to 69.4%) and pooled specificity of 72.0% (CI, 63.4% to 79.2%). The SIRS criteria had a pooled sensitivity of 88.1% (CI, 82.3% to 92.1%) and a pooled specificity of 25.8% (CI, 17.1% to 36.9%). Key points for hospitalists include: The qSOFA demonstrated lower sensitivity but higher specificity for mortality than the SIRS criteria. Although SIRS criteria are more sensitive for mortality than qSOFA (and therefore better for identifying patients with a low mortality risk), they are plagued by poor specificity (i.e., many patients with infection meet SIRS criteria despite having a low risk for mortality). The qSOFA was never intended to replace SIRS as a screening tool, nor as a prompt for initiating antibiotics. Rather, it was formulated to be a more accurate tool for recognizing patients at high risk for death, and it does seem to fulfill the promise of greater specificity. An editorial suggests that qSOFA and SIRS should be considered complementary tools with different strengths. The Latest Highlights From ACP Journal Club Is contrast-enhanced computed tomography associated with acute kidney injury or mortality? Review: In adults, contrast-enhanced CT is not linked to acute kidney injury or mortality vs noncontrast CT Ann Intern Med. 2017;168:JC10. doi:10.7326/ACPJC-2018-168-2-010 This meta-analysis of 28 observational studies (n = 107 335) compared patients receiving contrast-enhanced computed tomography with those receiving noncontrast computed tomography and found no association between acute kidney injury or death and the use of intravenous contrast. However, the observational nature of the included studies and the heterogeneity of the definitions of acute kidney injury used in the studies limit the conclusions of the analysis. In patients with cryptogenic stroke, does closure of a patent foramen ovale (PFO) reduce recurrent ischemic stroke more than treatment with antiplatelet drugs? Adding patent foramen ovale closure to antiplatelet drugs reduced ischemic stroke after cryptogenic stroke Ann Intern Med. 2017;168:JC6. doi:10.7326/ACPJC-2018-168-2-006 This summary highlights 2 randomized controlled trials (n = 664 for each) that compared antiplatelet therapy alone versus antiplatelet therapy plus PFO closure in patients with cryptogenic stroke found to have PFOs meeting specific criteria. In both trials, patients undergoing PFO closure had fewer recurrent strokes than those treated with medical therapy alone (first trial: NNT, 25 [95% CI, 21 to 50]; second trial: NNT, 18 [CI, 17 to 23]). Patients undergoing PFO closure procedures were significantly more likely to have atrial fibrillation. Sign up here to have Annals for Hospitalists delivered to your inbox each month.
Annals for Educators - 20 February 2018 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-20 Darren B. Taichman
Clinical Practice Points Mid- and Long-Term Health Risks in Living Kidney Donors. A Systematic Review and Meta-analysis Living kidney donation is the gold standard treatment of end-stage renal disease; more than 8000 living-donor kidney transplantations were done in 2013 in the United States, Brazil, and Japan alone. This systematic review of 52 observational studies details health risks for adults who donate kidneys. Use this study to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners what risks might accompany kidney donation. What did this systematic review and meta-analysis find? What medical and ethical issues must be considered and discussed with persons who are considering donating a kidney? How might the results of this review inform these discussions? What limitations in the available data were identified in this study? Why is the follow-up time so important? How should we counsel patients who inquire about donating a kidney? What questions do we need to ask? What do we need to tell them about the short- and long-term risks? The authors assessed whether the nondonor comparison groups were as healthy as the donors in the studies included in this meta-analysis. Why is that important? The authors found that most comparison groups were likely not as healthy as the kidney donors. How might that affect the findings and conclusions? Use the accompanying editorial to help frame your discussion of these questions, and invite a specialist in kidney transplantation to join your discussion. Chief Concern: “I'm Worried I Have Chronic Traumatic Encephalopathy” Chronic traumatic encephalopathy (CTE) has recently been the focus of extensive media attention. Are your learners prepared to address concerns that their patients might have? This commentary addresses diagnosis, prevention, treatment, and financial compensation for patients with a history of head trauma and their families. Use this paper to: Ask your learners what they know about CTE. How is it defined? Is it helpful to know about a disease entity that, at present, can only be diagnosed at autopsy? How? What symptoms and signs have been reported in patients with CTE? What is the differential diagnosis for each? Who is at risk for CTE? What is known (and not known) about the relationship between concussion and CTE? How would your learners respond to a patient who is concerned about CTE? How would they discuss the risks and benefits of participating in sports that might involve head trauma? What would they recommend patients (or parents whose children participate in sports) do? Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery. This substudy from a large multicenter trial examines benefits and harms of perioperative aspirin in patients with prior PCI undergoing noncardiac surgery. Use this study to: Ask your learners how they assess the risks for cardiac complications of noncardiac surgery. Who is at increased risk? Who requires testing, and how? Use In the Clinic: Preoperative Evaluation for Noncardiac Surgery to help prepare a teaching session. Review the results of this study. What are its strengths and limitations? Use the accompanying editorial to help frame your discussion. Why does it matter whether a study was prespecified by the investigators? Should your learners continue aspirin in noncardiac surgical patients who have had prior PCI? Who requires antiplatelet therapy after PCI? For how long? Watch The Consult Guys - An MI, a Stent, Bleeding, and Surgery! What Do I Do? with your learners for a relaxed way to review antiplatelet therapy after coronary stent placement. The ACC/AHA 2017 Hypertension Guidelines: Both Too Much and Not Enough of a Good Thing? The most notable recommendation in the 2017 hypertension guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) is the reduced threshold for the diagnosis of hypertension, from ≥140/90 mm Hg to ≥130/80 mm Hg in the general population. This commentary discusses the guidelines and why they create as many questions as they answer. Use this paper to: Ask your learners what threshold they use to diagnose hypertension. What do the guidelines from ACC/AHA and the American College of Physicians and American Academy of Family Physicians recommend? Why do they differ? How do blood pressure measurements obtained in your learners' practices differ from those obtained in the clinical trials whose results are used to formulate hypertension guidelines? What other important differences are there between a clinical trial and your learners' practices? The authors of this paper discuss how failure to recognize these differences might affect assessments of the quality of care provided by physicians. Do your learners think this is a problem? Can they suggest solutions? Humanism and Professionalism On Being a Doctor: Politics and Professionalism Dr. Sexauer writes that, “To many, [the 2016] election seemed to be as much a referendum on civility as it was about the political future of our country. Civility lost.” He asks how the medical profession should respond. Use this essay to: Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners whether differences in political opinions have affected their interactions with coworkers. What about with patients? How? Should we refrain from discussing political topics at work? Do your learners share the author's concern for civility in our society? What responsibilities does our profession have here? MKSAP 17 Question A 65-year-old woman is evaluated during a follow-up visit. She has end-stage kidney disease due to IgA nephropathy; she started peritoneal dialysis 3 months ago. She also has a 10-year history of hypertension. She has done well since starting dialysis, is without current complaints, and has recently resumed exercising regularly. She has three adult children who are encouraging her to explore kidney transplantation and are willing to be evaluated as kidney donors; however, the patient feels that she is “too old.” Medications are amlodipine, ramipril, calcitriol, epoetin alfa, and calcium acetate. On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 135/75 mm Hg, pulse rate is 72/min, and respiration rate is 14/min. BMI is 27. The peritoneal dialysis catheter site is nontender without induration or exudate. Cardiac examination reveals normal heart sounds. The lungs are clear. The abdomen is nontender. There is no peripheral edema. Which of the following kidney replacement strategies is most likely to provide this patient with the best long-term survival? A. Change from peritoneal dialysis to hemodialysis B. Continue peritoneal dialysis C. Continue peritoneal dialysis and evaluate for transplant in 2 to 3 years D. Refer for transplant evaluation now Correct Answer D. Refer for transplant evaluation now Educational Objective Understand the risks and benefits of kidney transplantation. Critique Kidney transplantation would be the most likely strategy to provide this patient with the best long-term survival. Although there is an increase in short-term morbidity and mortality following transplantation, there is strong evidence that kidney transplantation decreases mortality and improves quality of life over the long term. Even though increased recipient age is also associated with reduced patient and allograft survival than younger patients after transplant, carefully selected older patients also benefit from kidney transplantation, and many centers therefore do not have an absolute age cutoff for transplant recipients. Moreover, this patient has family members who are willing to be evaluated as living kidney donors, and kidneys from living donors have superior outcomes compared with kidneys from deceased donors. Therefore, referral for possible kidney transplant in this otherwise healthy patient would be most likely to improve her long-term survival. There is no clinical indication for this patient to change from peritoneal dialysis to hemodialysis, and clinical outcomes, including mortality and quality of life, are approximately equivalent between these modalities. The choice between peritoneal dialysis and hemodialysis should therefore be driven by patient-specific factors and patient preference if dialysis is pursued. There is evidence that risk of graft loss and overall mortality are increased in patients who have been treated with dialysis prior to transplant, and that this risk of graft loss and overall mortality increase with the length of dialysis prior to transplant. Therefore, continuing dialysis and reevaluating for possible transplant in 2 to 3 years would not be an optimal management strategy in this otherwise good candidate for transplantation. Key Point Kidney transplantation decreases long-term mortality and improves quality of life compared with dialysis. Bibliography Tonelli M, Wiebe N, Knoll G, et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant. 2011 Oct;11(10):2093-109. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-20 Markus Ketteler, Geoffrey A. Block, Pieter Evenepoel, Masafumi Fukagawa, Charles A. Herzog, Linda McCann, Sharon M. Moe, Rukshana Shroff, Marcello A. Tonelli, Nigel D. Toussaint, Marc G. Vervloet, Mary B. Leonard
Description: The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD–MBD) is a selective update of the prior CKD–MBD guideline published in 2009. The guideline update and the original publication are intended to assist practitioners caring for adults with CKD and those receiving long-term dialysis. Methods: Development of the guideline update followed an explicit process of evidence review and appraisal. The approach adopted by the Work Group and the evidence review team was based on systematic reviews of relevant trials, appraisal of the quality of the evidence, and rating of the strength of recommendations according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Searches of the English-language literature were conducted through September 2015 and were supplemented with targeted searches through February 2017. Final modification of the guidelines was informed by a public review process involving numerous stakeholders, including patients, subject matter experts, and industry and national organizations. Recommendations: The update process resulted in the revision of 15 recommendations. This synopsis focuses primarily on recommendations for diagnosis of and testing for CKD–MBD and treatment of CKD–MBD that emphasizes decreasing phosphate levels, maintaining calcium levels, and addressing elevated parathyroid hormone levels in adults with CKD stage G3a to G5 and those receiving dialysis. Key elements include basing treatment on trends in laboratory values rather than a single abnormal result and being cautious to avoid hypercalcemia when treating secondary hyperparathyroidism.
Treatment-Free Remission After Second-Line Nilotinib Treatment in Patients With Chronic Myeloid Leukemia in Chronic Phase: Results From a Single-Group, Phase 2, Open-Label Study Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-20 François-Xavier Mahon, Carla Boquimpani, Dong-Wook Kim, Noam Benyamini, Nelma Cristina D. Clementino, Vasily Shuvaev, Sikander Ailawadhi, Jeffrey Howard Lipton, Anna G. Turkina, Raquel De Paz, Beatriz Moiraghi, Franck E. Nicolini, Jolanta Dengler, Tomasz Sacha, Naoto Takahashi, Rafik Fellague-Chebra, Sandip Acharya, Stephane Wong, Yu Jin, Timothy P. Hughes
Background: Treatment-free remission (TFR)—that is, stopping tyrosine kinase inhibitor (TKI) therapy without loss of response—is an emerging treatment goal in chronic myeloid leukemia (CML). Objective: To evaluate TFR after discontinuation of second-line nilotinib therapy. Design: Single-group, phase 2, open-label study. (ClinicalTrials.gov: NCT01698905) Setting: 63 centers in 18 countries. Patients: Adults with CML in chronic phase who received TKI therapy for at least 3 years (>4 weeks with imatinib, then ≥2 years with nilotinib) and achieved MR4.5 (BCR-ABL1 ≤0.0032% on the International Scale [BCR-ABL1IS]) while receiving nilotinib entered a 1-year consolidation phase. Those with sustained MR4.5 during consolidation were eligible to enter TFR. Interventions: Patients received nilotinib during consolidation; those who entered TFR stopped treatment. Patients with loss of major molecular response (MMR) (BCR-ABL1IS ≤0.1%) or confirmed loss of MR4 (BCR-ABL1IS ≤0.01%) during TFR reinitiated nilotinib treatment. Measurements: Proportion of patients without loss of MMR, confirmed loss of MR4, or treatment reinitiation within 48 weeks of stopping treatment (primary end point). Results: 163 patients who had switched from imatinib to nilotinib (for reasons including resistance, intolerance, and physician preference) enrolled in the study and entered the consolidation phase. Of these patients, 126 met the criteria for entering the TFR phase, and 73 (58% [95% CI, 49% to 67%]) and 67 (53% [CI, 44% to 62%]) maintained TFR at 48 weeks (primary end point) and 96 weeks, respectively. Of the 56 patients who reinitiated nilotinib therapy, 55 regained MMR or better and 52 regained MR4.5. None had CML progression to accelerated phase or blast crisis. Musculoskeletal pain was more frequent during the first 48 weeks after nilotinib discontinuation. Limitation: The study included a heterogeneous patient population and was not designed to compare outcomes between patients continuing and those stopping treatment. Conclusion: TFR seems achievable in patients with sustained MR4.5 after switching to nilotinib. Primary Funding Source: Novartis Pharmaceuticals Corporation.
Hydroxychloroquine Effectiveness in Reducing Symptoms of Hand Osteoarthritis: A Randomized Trial Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-20 Sarah R. Kingsbury, Puvan Tharmanathan, Ada Keding, Sarah J. Ronaldson, Andrew Grainger, Richard J. Wakefield, Catherine Arundel, Fraser Birrell, Michael Doherty, Tonia Vincent, Fiona E. Watt, Krysia Dziedzic, Terence W. O'Neill, Nigel K. Arden, David L. Scott, John Dickson, Toby Garrood, Michael Green, Ajit Menon, Tom Sheeran, David Torgerson, Philip G. Conaghan
Background: Synovitis is believed to play a role in producing symptoms in persons with hand osteoarthritis, but data on slow-acting anti-inflammatory treatments are sparse. Objective: To determine the effectiveness of hydroxychloroquine versus placebo as an analgesic treatment of hand osteoarthritis. Design: Randomized, double-blind, placebo-controlled clinical trial with 12-month follow-up. (ISRCTN registry number: ISRCTN91859104) Setting: 13 primary and secondary care centers in England. Participants: Of 316 patients screened, 248 participants (82% women; mean age, 62.7 years) with symptomatic (pain ≥4 on a 0- to 10-point visual analogue scale) and radiographic hand osteoarthritis were randomly assigned and 210 (84.7%) completed the 6-month primary end point. Intervention: Hydroxychloroquine (200 to 400 mg) or placebo (1:1) for 12 months with ongoing usual care. Measurements: The primary end point was average hand pain during the previous 2 weeks (on a 0- to 10-point numerical rating scale [NRS]) at 6 months. Secondary end points included self-reported pain and function, grip strength, quality of life, radiographic structural change, and adverse events. Baseline ultrasonography was done. Results: At 6 months, mean hand pain was 5.49 points in the placebo group and 5.66 points in the hydroxychloroquine group, with a treatment difference of −0.16 point (95% CI, −0.73 to 0.40 point) (P = 0.57). Results were robust to adjustments for adherence, missing data, and use of rescue medication. No significant treatment differences existed at 3, 6, or 12 months for any secondary outcomes. The percentage of participants with at least 1 joint with synovitis was 94% (134 of 143) on grayscale ultrasonography and 59% on power Doppler. Baseline structural damage or synovitis did not affect treatment response. Fifteen serious adverse events were reported (7 in the hydroxychloroquine group [3 defined as possibly related] and 8 in the placebo group). Limitation: Hydroxychloroquine dosage restrictions may have reduced efficacy. Conclusion: Hydroxychloroquine was no more effective than placebo for pain relief in patients with moderate to severe hand pain and radiographic osteoarthritis. Primary Funding Source: Arthritis Research UK.
Benefits and Harms of Cranial Electrical Stimulation for Chronic Painful Conditions, Depression, Anxiety, and Insomnia: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-13 Paul G. Shekelle, Ian A. Cook, Isomi M. Miake-Lye, Marika Suttorp Booth, Jessica M. Beroes, Selene Mak
Background: Cranial electrical stimulation (CES) is increasingly popular as a treatment, yet its clinical benefit is unclear. Purpose: To review evidence about the benefits and harms of CES for adult patients with chronic painful conditions, depression, anxiety, and insomnia. Data Sources: Several databases from inception to 10 October 2017 without language restrictions and references from experts, prior reviews, and manufacturers. Study Selection: Randomized controlled trials of CES versus usual care or sham CES that reported pain, depression, anxiety, or sleep outcomes in any language. Data Extraction: Single-reviewer extraction checked by another; dual independent quality assessment; strength-of-evidence grading by the first author with subsequent group discussion. Data Synthesis: Twenty-eight articles from 26 randomized trials met eligibility criteria. The 2 trials that compared CES with usual care were small, and neither reported a statistically significant benefit in pain or anxiety outcomes for patients with fibromyalgia or anxiety, respectively. Fourteen trials with sham or placebo controls involving patients with painful conditions, such as headache, neuromuscular pain, or musculoskeletal pain, had conflicting results. Four trials done more than 40 years ago and 1 from 2014 provided low-strength evidence of a possible modest benefit compared with sham treatments in patients with anxiety and depression. Trials in patients with insomnia (n = 2), insomnia and anxiety (n = 1), or depression (n = 3) had inconclusive or conflicting results. Low-strength evidence suggested that CES does not cause serious side effects. Limitation: Most trials had small sample sizes and short durations; all had high risk of bias due to inadequate blinding. Conclusion: Evidence is insufficient that CES has clinically important effects on fibromyalgia, headache, neuromusculoskeletal pain, degenerative joint pain, depression, or insomnia; low-strength evidence suggests modest benefit in patients with anxiety and depression. Primary Funding Source: Veterans Affairs Quality Enhancement Research Initiative. (PROSPERO: CRD42016023951)
Opioid Analgesic Use and Risk for Invasive Pneumococcal Diseases: A Nested Case–Control Study Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-13 Andrew D. Wiese, Marie R. Griffin, William Schaffner, C. Michael Stein, Robert A. Greevy, Edward F. Mitchel, Carlos G. Grijalva
Background: Although certain opioid analgesics have immunosuppressive properties and increase the risk for infections in animals, the clinical effects of prescription opioid use on infection risk among humans are unknown. Objective: To test the hypothesis that prescription opioid use is an independent risk factor for invasive pneumococcal disease (IPD). Design: Nested case–control study. Setting: Tennessee Medicaid database linked to Medicare and Active Bacterial Core surveillance system databases (1995 to 2014). Patients: 1233 case patients with IPD aged 5 years and older matched to 24 399 control participants by diagnosis date, age, and county of residence. Measurements: Opioid use was measured on the basis of pharmacy prescription fills. Invasive pneumococcal disease was defined by the isolation of Streptococcus pneumoniae from a normally sterile site. The odds of current opioid use were compared between the case and control groups, accounting for known IPD risk factors. Secondary analyses categorized opioid use by opioid characteristics, applied an IPD risk score to assure comparability between exposure groups, and analyzed pneumonia and nonpneumonia IPD cases separately. Results: Persons in the case group had greater odds than control participants of being current opioid users (adjusted odds ratio [aOR], 1.62 [95% CI, 1.36 to 1.92]). Associations were strongest for opioids that were long acting (aOR, 1.87 [CI, 1.24 to 2.82]), of high potency (aOR, 1.72 [CI, 1.32 to 2.25]), or were used at high dosages (50 to 90 morphine milligram equivalents [MME]/d: aOR, 1.71 [CI, 1.22 to 2.39]; ≥90 MME/d: aOR, 1.75 [CI, 1.33 to 2.29]). Results were consistent when the IPD risk score was taken into account and pneumonia and nonpneumonia IPD were analyzed separately. Limitations: Unmeasured confounding and measurement error, although sensitivity analyses suggested that neither was likely to affect results. Actual opioid use and other nonprescription use (such as illicit opioid use) were not measured. Conclusion: Opioid use is associated with an increased risk for IPD and represents a novel risk factor for these diseases. Primary Funding Source: National Institutes of Health.
Hot Tea Consumption and the Risk for Esophageal Cancer Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-06
What is the problem and what is known about it so far? Esophageal cancer is a serious and often fatal disease involving the uncontrolled growth of cells in the esophagus, the tube that carries food and liquids from the mouth to the stomach. Drinking alcohol excessively and smoking on a regular basis are each known to increase the risk for esophageal cancer. Although previous studies suggested that drinking boiling-hot tea might also increase the risk for esophageal cancer, they could not assess whether this observation was the result of alcohol or tobacco use. Why did the researchers do this particular study? To determine whether people who drink hot or boiling-hot tea on a regular basis are at risk for esophageal cancer, even when accounting for alcohol and tobacco use. Who was studied? 456,155 men and women in China, aged 30 to 79 years, who were not known to have cancer at the start of the study. How was the study done? The researchers collected information regarding people's tea-drinking habits, tobacco and alcohol consumption, and other health-related variables. They then followed the study participants for more than 9 years to see whether any of them developed esophageal cancer. What did the researchers find? Participants who reported drinking hot or boiling-hot tea daily at the beginning of the study were at increased risk for esophageal cancer during the study if they also drank 15 grams of alcohol or more per day or currently smoked tobacco. A 12-ounce glass of regular beer, a 5-ounce glass of table wine, and a 1.5-ounce shot of distilled spirits (such as vodka, gin, or whiskey) each contain about 14 grams of alcohol. No increase in esophageal cancer risk was seen among participants who drank hot tea if they did not also drink more than 15 grams of alcohol daily and smoke tobacco. What were the limitations of the study? Participants' tea-drinking habits, as well as their alcohol and tobacco use, may have changed during the study period. What are the implications of the study? People who drink alcohol excessively or smoke tobacco are known to be at increased risk for esophageal cancer. Drinking hot or boiling-hot tea might make that risk even higher.
Cellulitis and Soft Tissue Infections Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-06 Rachel Bystritsky, Henry Chambers
Cellulitis and soft tissue infections are a diverse group of diseases that range from uncomplicated cellulitis to necrotizing fasciitis. Management of predisposing conditions is the primary means of prevention. Cellulitis is a clinical diagnosis and thus is made on the basis of history and physical examination. Imaging may be helpful for characterizing purulent soft tissue infections and associated osteomyelitis. Treatment varies according to the type of infection. The foundations of treatment are drainage of purulence and antibiotics, the latter targeted at the infection's most likely cause.
Annals for Educators - 6 February 2018 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-06 Darren B. Taichman
Clinical Practice Points Improving Decisions About Transport to the Emergency Department for Assisted Living Residents Who Fall Falling is a frequent problem for residents of assisted living facilities. The problem is aggravated when institutional policy requires transport to an emergency department after every fall, even when there is little or no injury. The paramedics who provide emergency medical services and some of the primary care physicians who provide care in 1 geographic area worked together to address this problem. The result was a remarkable improvement. Use this study to: Ask your learners what questions they ask when contacted about patients who have fallen. What do they look for on physical examination? On what basis do your learners decide whether further evaluation is necessary (e.g., transport to the hospital or further assessments for patients who are already hospitalized)? Review the algorithm used for this study (presented in Figure 1 in the paper's Supplement). Do your learners like this approach to triage? Review the results of this study. Do your learners think the approach is sound? Why or why not? What are the benefits of such an approach? What are the risks? How big of a problem are falls among residents of assisted living facilities? Are the results of this study generalizable? Use the accompanying editorial to help frame your discussion. Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018 The Advisory Committee on Immunization Practices (ACIP) presents the recommended immunization schedule for adults aged 19 years or older for 2018. This schedule has been approved by the ACIP, the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives. Use this guideline to: Start a teaching session with a multiple-choice question. We've provided one below! Review the recommended immunization schedule with your learners. What's new this year? What changed in the recommendations regarding MMR immunization? How about zoster vaccination? Ask your learners whether they think they do a good job of reviewing their patients' immunization status. What systems are in place in your practice to facilitate keeping patients up to date with immunizations? Are they effective? How do you know for sure? Invite someone from your organization's quality improvement group to review what is known about how well your practice performs in adult immunization. Ask your learners where the problems lie, and ask them to design interventions to address each problem. How would they assess whether each intervention works? Will your institution try them? Beyond the Guidelines Should This Patient Receive Hormone Therapy for Her Menopausal Symptoms? Grand Rounds Discussion From Beth Israel Deaconess Medical Center Use of hormone therapy (HT) for the vasomotor symptoms of menopause has been controversial since publication of the Women's Health Initiative trial in the early 2000s. However, the 2017 guideline from the North American Menopause Society recommends HT for these symptoms. Here, 2 experts discuss the guideline and whether to prescribe HT to Ms. R, a 52-year-old woman with severe hot flashes, sleep disturbance, and irritability. Use this feature to: Ask your learners what symptoms may be due to perimenopause and menopause. How are they diagnosed? Is testing required? Use the recent In the Clinic: Perimenopause to find answers quickly. Watch an interview of Ms. R with your learners. Ask your learners what treatment options are available for Ms. R's symptoms. If treatment is started, how long should it be continued? Watch or have your learners read the presentations by 2 expert clinicians whose answers to these questions differ. Now what would your learners do? Download the prepared slides to help prepare for teaching. Use the multiple-choice questions to help reinforce learning points, and log on to enter your answers and earn CME/MOC credit for yourself! In the Clinic In the Clinic: Cellulitis and Soft Tissue Infections Bacterial skin and soft tissue infections are a diverse group of diseases ranging from uncomplicated cellulitis, which can be treated in the outpatient setting with oral antibiotics, to necrotizing fasciitis, a life-threatening condition that requires emergent surgical debridement. Are your learners prepared to appropriately evaluate and manage these problems? Use this review to: Ask who is at increased risk for cellulitis and soft tissue infections. What preventive measures should be taken? Is antibiotic prophylaxis ever indicated? What is the differential diagnosis of cellulitis and soft tissue infections? When are laboratory tests indicated, and which ones? When are topical, oral, or intravenous antibiotics indicated? When should surgical intervention be considered? How is necrotizing fasciitis diagnosed? Download the teaching slides to help with a teaching session, and break it up with the multiple-choice questions to help introduce new topics. Be sure to log on and enter the answers to earn CME/MOC credit for yourself! Humanism and Professionalism On Being a Doctor: Long Coat Doctor “The letter was on my desk when I returned from lunch. Though its plain envelope was unremarkable, the name on the return address caught my attention and unlocked a distant memory.”—Dr. Bertram recalls his role in turning around a struggling medical student. Use this essay to: Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners to think about the teachers and mentors who made a difference in their lives. What qualities made them so influential? Do your learners consider themselves teachers? Of whom? Have they had opportunities to help students in need of extra attention? Did they find the time to help? How did it affect their students? How has it rewarded them as teachers? Have they missed such opportunities? Why? Does teaching come more naturally to some of us? How can thinking about our own experiences as students help us be better teachers? What motivates us to teach? MKSAP 17 Question A 17-year-old girl is evaluated during a routine preventive examination. She is a college student. Medical history is unremarkable, and she is not and has never been pregnant. A review of the patient's immunization records reveals that she received a complete human papillomavirus vaccine series, and she is up to date on tetanus, diphtheria, and acellular pertussis immunization. She received the quadrivalent meningococcal conjugate vaccine at age 12 years, with a booster vaccine at age 16 years. She takes no medications. Findings on physical examination are unremarkable. According to recommendations of the Advisory Committee on Immunization Practices, which of the following is the most appropriate management to offer this patient? A. Herpes zoster vaccine B. Meningococcal serogroup B vaccine C. 13-Valent pneumococcal conjugate vaccine D. No vaccination at this time Correct Answer B. Meningococcal serogroup B vaccine Educational Objective Offer vaccination against serogroup B meningococcal disease to an adolescent patient. Critique The most appropriate management is to offer this patient the meningococcal serogroup B (MenB) vaccine. Meningococcal disease is rare (estimated incidence of 0.18 per 100,000 among persons of all ages), but each case is rapidly life threatening. The Advisory Committee on Immunization Practices (ACIP) recommends that all individuals be vaccinated by age 18 years against serogroups A, C, Y, and W135 with the quadrivalent meningococcal conjugate vaccine; however, the quadrivalent vaccine does not offer protection against serogroup B. In October 2015, the ACIP recommended that adolescents and young adults aged 16 to 23 years may be vaccinated with the MenB vaccine, with a preference to vaccinate between ages 16 and 18 years. This ACIP recommendation is classified as category B (recommended for individual clinical decision making). Two MenB vaccines were recently licensed by the FDA: MenB-FHbp and MenB-4C. Both were licensed under an accelerated approval pathway, and thus confirmatory studies in the postmarketing period will be conducted. Because the prevalence of disease is low, and postmarketing data are not yet available regarding safety and efficacy, the ACIP determined that there was insufficient evidence to make a routine recommendation that all adolescents be vaccinated with a MenB vaccine. In patients who choose to be vaccinated, the MenB vaccine can be administered concomitantly with other vaccines. Pregnant and lactating women should not be vaccinated unless they are at high risk. High-risk conditions include persistent complement deficiencies, treatment with the terminal complement inhibitor eculizumab, and anatomic or functional asplenia including sickle cell disease. Healthy persons may also be identified as having increased risk due to a serogroup B meningococcal outbreak. In healthy adults such as this one, the 13-valent pneumococcal conjugate vaccine (PCV13) is recommended at age 65 years. Although varicella vaccines are given in childhood, with catch-up series provided for individuals who have not had primary chicken pox or the vaccination series, the ACIP recommends the herpes zoster vaccine for shingles prevention at age 60 years in otherwise healthy adults. Key Point The Advisory Committee on Immunization Practices recommends that adolescents and young adults aged 16 to 23 years may be vaccinated with serogroup B meningococcal (MenB) vaccine. Bibliography MacNeil JR, Rubin L, Folaranmi T, Ortega-Sanchez IR, Patel M, Martin SW. Use of serogroup B meningococcal vaccines in adolescents and young adults: recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep. 2015 Oct 23;64(41):1171-6. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Correction: On the Communicability of Chronic Diseases Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-06
Dr. Jeremiah Barondess, author of a recent article (1), is affiliated with the Columbia University Mailman School of Public Health, not the New York Academy of Medicine. This has been corrected. References Demmer RT Barondess JA On the communicability of chronic diseases Ann Intern Med 2018 168 69 70 CrossRef PubMed
Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018* Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-06 David K. Kim, Laura E. Riley, Paul Hunter
In October 2017, the Advisory Committee on Immunization Practices (ACIP) voted to approve the Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018. The 2018 adult immunization schedule summarizes ACIP recommendations in 2 figures and a table of contraindications and precautions for vaccines recommended for adults (Figure). They can be found at www.cdc.gov/vaccines/schedules. The full ACIP recommendations for each vaccine is available at www.cdc.gov/vaccines/hcp/acip-recs/index.html. The 2018 adult immunization schedule has also been approved by the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives. The ACIP-recommended use of each vaccine is developed after in-depth reviews of vaccine-related data, including disease epidemiology, vaccine efficacy and effectiveness, vaccine safety, feasibility of program implementation, and economic aspects of immunization policy (1). The purpose of the adult immunization schedule is to assist health care providers in implementing the current ACIP recommendations for vaccinating adults. Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018. Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018. In addition to the figures that display vaccination recommendations based on age and medical conditions and other indications and a Table of contraindications and precautions for vaccinations, the adult immunization schedule contains information on general principles on immunization for adults; considerations for special populations, such as pregnant women; reference resources pertinent to adult immunization; instructions for reporting adverse events and suspected cases of reportable vaccine-preventable diseases; and an ACIP-approved list of standardized abbreviations for vaccines recommended for adults. The 2 figures in the adult immunization schedule are accompanied by footnotes that should be reviewed with Figures 1 and 2. These footnotes provide important details on vaccination recommendations, such as the number of doses in a vaccination series and dosing intervals. Changes in the 2018 adult immunization schedule from the previous year's schedule include new ACIP recommendations on the use of recombinant zoster vaccine (RZV) for adults aged 50 years or older and the use of an additional dose of measles, mumps, and rubella vaccine (MMR) in a mumps outbreak setting. Table. Table. Contraindications and precautions for vaccines recommended for adults aged 19 years or older Figure 1. Recommended immunization schedule for adults aged 19 years or older, by age group, United States, 2018. Figure 2. Recommended immunization schedule for adults aged 19 years or older, by medical condition and other indications, United States, 2018. Footnotes. Footnotes. Footnotes. Footnotes. Continued Zoster vaccination (2). On 20 October 2017, the U.S. Food and Drug Administration approved the use of RZV (Shingrix, GlaxoSmithKline) for adults aged 50 years or older for the prevention of herpes zoster (shingles) and its complications. On 25 October, the ACIP recommended the use of 1) RZV among immunocompetent adults aged 50 years or older for the prevention of herpes zoster and related complications, 2) RZV among adults aged 50 years or older who previously received the zoster vaccine live (ZVL) (Zostavax, Merck & Co.), and 3) either RZV or ZVL for adults aged 60 years or older (RZV is preferred). On 26 October, the ACIP recommended the following in the 2018 adult immunization schedule: • Administer 2 doses of RZV 2–6 months apart to adults aged 50 years or older regardless of past episode of herpes zoster or receipt of ZVL. • Administer 2 doses of RZV 2–6 months apart to adults who previously received ZVL at least 2 months after ZVL. • For adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred). The clinical trials for RZV excluded pregnancy and confirmed or suspected immunocompromising conditions that can result from disease, such as malignancy and HIV infection, or therapy, such as cancer chemotherapy and treatment for autoimmune disorders (3–6). Therefore, there is currently no ACIP recommendation on the use of RZV among pregnant women (health care providers should consider delaying administration of RZV for pregnant women) or adults with immunocompromising conditions, including HIV infection (additional discussions and recommendations by the ACIP on the use of RZV in adults with immunocompromising conditions are pending). Consistent with the existing recommended use of ZVL, the ACIP recommended RZV for adults who are receiving low-dose immunosuppressive therapy, are anticipating immunosuppression, or have recovered from an immunocompromising illness (7). Additionally, as the clinical trials for RZV did not exclude adults with non-immunocompromising chronic health conditions (3–6), and given the safety and effectiveness profiles of other conjugate vaccines recommended for adults, such as hepatitis B and pneumococcal vaccines, the ACIP recommended that RZV should routinely be used for adults with diabetes mellitus; chronic heart, lung, liver, or kidney disease; functional or anatomical asplenia; or complement deficiencies who meet the age criterion. Note that ZVL is contraindicated for pregnant women and adults with severe primary or acquired immunodeficiency, including those with HIV infection and a CD4 cell count <200 cells/µL (there is no recommendation for ZVL for adults with HIV infection and a CD4 cell count ≥200 cells/µL). MMR vaccination (8). On 25 October, the ACIP updated MMR vaccination recommendations to include the use of a third dose of a mumps-containing vaccine for persons previously vaccinated with 2 doses of a mumps-containing vaccine who are identified to by public health authorities as being a part of a group or population at risk for acquiring mumps because of an outbreak. For implementation purposes, the recommendation is that, during a mumps outbreak, persons identified as being at increased risk and who have received ≤2 doses of mumps virus–containing vaccine or have unknown vaccination status should receive 1 dose of MMR. This change is described in the 2018 adult immunization schedule as: • Administer 1 dose of MMR to adults who previously received ≤2 doses of mumps-containing vaccine and are identified by a public health authority to be at increased risk during a mumps outbreak. Adults without evidence of immunity to mumps (defined as: born before 1957, have documented receipt of MMR, or have laboratory evidence of immunity or disease) are routinely recommended to receive 1 dose of MMR for mumps prevention unless they are students in postsecondary educational institutions, international travelers, or household contacts of immunocompromised persons, in which case they should receive 2 doses of MMR at least 28 days apart. In a mumps outbreak setting, those adults identified by a public health authority to be at risk should receive 1 dose of MMR regardless of whether they previously received 0, 1, or 2 doses of a mumps-containing vaccine. Notable changes in the Figures are: • In Figures 1 and 2, “ZVL” replaced the term “HZV” (herpes zoster vaccine) that was used in past adult immunization schedules to refer to the live zoster vaccine. A row for RZV was added above the row for ZVL to distinguish the 2 zoster vaccines and a dashed line was used to separate RZV and ZVL rows to denote that the 2 zoster vaccines are recommended for the same purpose. In the indication bars for RZV, the text that RZV is preferred over ZVL has been added when either RZV or ZVL can be used for adults aged 60 years or older. • In Figures 1 and 2, “Td/Tdap” (tetanus and reduced diphtheria toxoids/tetanus and reduced diphtheria toxoids and acellular pertussis vaccine) has been replaced by “Tdap or Td” and the text in the indication bar has been revised to “1 dose Tdap, then Td booster every 10 years.” One dose of Tdap is recommended for adults who have not previously received Tdap as an adult or child (1 dose of Tdap is routinely recommended at age 11–12 years), except for pregnant women who are recommended to receive 1 dose of Tdap for each pregnancy during the early part of gestational weeks 27–36. • In Figures 1 and 2, the text in the indication bar for MenACWY (serogroups A, C, W, and Y meningococcal vaccine) has been revised to “1 or 2 doses depending on indication, then booster every 5 years if risk remains.” Adults with functional or anatomical asplenia, persistent complement component deficiencies, or HIV infection should receive 2 doses of MenACWY and revaccinate every 5 years. One dose of MenACWY is recommended for microbiologists who to work with isolates of Neisseria meningitidis and travelers in countries with endemic or epidemic meningococcal disease, and a booster dose of MenACWY is indicated every 5 years if the risk remains. First-year college students living in residence halls and military recruits are also recommended to receive 1 dose of MenACWY. MPSV4 (4-valent meningococcal polysaccharide vaccine) is no longer available and has been removed from the adult immunization schedule. • In Figure 1, the text in the indication bar for MMR has been changed to “1 or 2 doses depending on indication (if born in 1957 or later).” Adults born in 1957 or later who do not have evidence of immunity to measles, mumps, or rubella are routinely recommended to receive 1 dose of MMR. However, students in postsecondary educational institutions, international travelers, and household contacts of immunocompromised persons are routinely recommended to receive 2 doses of MMR at least 28 days apart. • In Figure 1, the text in the indication bars for human papillomavirus (HPV) vaccine for females and males has been revised to “2 or 3 doses depending on age at series initiation.” In 2016, the recommended number of doses of HPV vaccine was revised to 2 or 3 depending on the age at which the HPV vaccination series began (9). Before 2016, 3 doses of HPV vaccine was recommended for adolescents and young adults. In 2016, for adolescents and young adults whose HPV vaccination series was initiated before age 15 years, 2 doses of HPV vaccine was recommended. That is, adult females through age 26 years and adult males through age 21 years (and adult males aged 22 through 26 years who may be vaccinated based on individual clinical decision) who received 2 doses of HPV vaccine at least 5 months apart at age 9–14 years are considered fully immunized. Those who received 1 dose of HPV vaccine or 2 doses of HPV vaccine less than 5 months apart at age 9–14 years are recommended to receive 1 additional dose of HPV vaccine at least 5 months after the last dose. Those who previously have not received any HPV vaccine should receive 3 doses at 0, 1-2, and 6 months (minimum intervals: 4 weeks between doses 1 and 2, 12 weeks between doses 2 and 3, and 5 months between doses 1 and 3; repeat doses if they were given too soon). Males and females through age 26 years with immunocompromising conditions, including HIV infection, are recommended to receive 3 doses of HPV vaccine. Men who have sex with men and transgender persons through age 26 years are recommended to receive 2 or 3 doses of HPV vaccine depending on the age at which they started their HPV vaccination series. The (footnotes in the 2018 adult immunization schedule should be read when reviewing Figures 1 and 2. The (footnotes contain additional general information, such as dosing intervals for vaccination series, and considerations for special populations, such as pregnant women and adults with HIV infection. The (footnotes in the adult immunization schedule and the child and adolescent immunization schedule have been harmonized to read more consistently (10). Although modest increases in vaccination coverage rates were observed in several groups of adult population in 2015, the overall vaccination coverage rates for adults in the United States have remained low (11). Among adults, modest increases in influenza vaccination (44.8%, an increase of 1.6 percentage points), Tdap vaccination (23.1%, an increase of 3.1 percentage points), pneumococcal vaccination among adults aged 19–64 years who are at increased risk for pneumococcal disease (23.0%, an increase of 3.3 percentage points), and zoster vaccination among adults aged 60 years or older (30.6%, an increase of 2.7 percentage points) were observed when compared with 2014. Except for the gradual but consistent increase in zoster vaccination among adults aged 60 years or older, no sustained increases in vaccination coverage for adults were seen over several years. In response to the persistently low vaccination coverage rates among adults, the National Vaccine Advisory Committee updated the standards for adult immunization practice to promote the integration of vaccinations as a part of routine clinical care for adults (12). The standards for adult immunization practice is a call to action for health care providers to 1) assess the vaccination status of adult patients at every clinical encounter, 2) strongly recommend needed vaccines to patients, 3) offer vaccines recommended to patients (providers who do not stock vaccines should refer patients to another provider or pharmacist who stocks and administers vaccines), and 4) document vaccines administered in the state or local immunization information system (IIS). The standards for adult immunization practice is the framework with which health care providers are encouraged to implement specific evidence-based strategies to improve the uptake of vaccines by their adult patients, such as designing patient flow to include immunization services, recommending and offering vaccines during the same clinical visit, utilizing standing orders to routinely administer vaccines, and using the IIS to document patient vaccination records and to assess their vaccination status (12). Also known as vaccination registries, IIS are confidential, electronic systems that collect and consolidate vaccination data from vaccination service providers (13). When automated and interoperable with electronic health record (EHR) systems, IIS can lend clinical decision support for the provider, generate reminders for providers, create notifications for patients, generate vaccination data reports for individual patients or groups of patients, help manage vaccine inventories, and other vaccination activities. Immunization programs in all states and municipalities have the authority to collect vaccination records for all age groups (“lifelong IIS”), except Rhode Island and Connecticut, where IIS are limited to vaccination records for children (14). Fifty-five immunization programs in 49 states (the New Hampshire legislature approved the establishment and use of statewide IIS in 2016 and its implementation is pending) and 6 cities (Chicago, District of Columbia, Houston, New York city, Philadelphia, and San Antonio) operate IIS (13). IIS in these state and city immunization programs have matured individually and their capabilities vary. Collectively, they are increasingly becoming important infrastructure for clinical point-of-care and population-level vaccination strategies. Reports submitted by immunization programs estimate that the percentage of adults with 1 or more vaccinations documented in IIS was 25% in 2008, 25% in 2012, and 44% in 2016 (15–17). Note that these percentages reflect a minimum of 1 routinely recommended vaccination documented for adults documented in IIS, far fewer than what they need to be current. In contrast, IIS participation by children younger than 6 years of age with 2 or more vaccinations documented in IIS was 63% in 2006, 86% in 2012, and 94% in 2016 (15, 18). Historically, the primary focus of IIS has been on pediatric populations, particularly with the role of the IIS in supporting Vaccines for Children, a federally funded program that provides vaccines at no cost to children who might not otherwise get vaccinated (19). IIS for children have been successful largely through partnerships with pediatricians and family practitioners who provide “medical homes” for children and routinely use IIS to assess and document pediatric vaccination records. In addition, mandates for vaccinating children, such as vaccination requirements for school entry, compel pediatricians and family practitioners to maintain accurate and current vaccination records for children in IIS. In contrast, adults are vaccinated by multiple health care providers, including specialty care providers, such as obstetricians and cardiologists, in frequently changing “medical homes” due to changes in employment status or health insurance plans, and often in settings outside of health care provider offices or health centers, such as pharmacies, retail clinics, and the workplace. That is, vaccination records for adults are often scattered, incomplete, and difficult to keep up to date. Consolidated adult vaccination records maintained in IIS would, therefore, play an important role in providing point-of-care clinical support for health care providers for adults. Having consolidated vaccination records for adults in IIS necessarily means that health care providers submit adult vaccination records to IIS. In a 2016 survey of approximately 1,300 health care providers whose practices included vaccination services for adults, more than 90% reported routinely assessing their patients for vaccinations, but only 32% reported that their practices submitted adult vaccination records to the IIS in their state or city (Lutz CS, Kim D, Black CL, et al. Implementation of adultimmunization practice standards by US clinicians and pharmacists. In preparation.). In contrast, in a 2013 survey of 627 pediatricians who offered vaccinations to their patients, approximately 90% reported using the IIS in their state or city (20). Health care providers and state and municipal immunization programs increasingly depend on technology to document and maintain updated vaccination records. IIS are an underused tool for primary care providers, including primary care providers; specialty care providers, such as obstetricians and gynecologists; occupational health clinic providers; and pharmacists. The use of IIS is a proven systematic approach that can help health care systems and providers make efficient and effective decisions on vaccinating their adult patients (21, 22). IIS can assist health care providers utilize adult vaccination as a quality measure to report to different payers. For example, health care providers who participate in the Medicare Quality Payment Program's Merit-based Incentive Payment System could use IIS data, such as pneumococcal vaccination records for adults aged 65 years or older, to submit as a quality measure (23). Bidirectional data exchanges between provider EHRs and IIS automate vaccination updates and promote high vaccination coverage. In 2016, IIS in 91% of 49 states and 6 cities received patient vaccination records submitted by health care providers, and 67% received and responded to provider requests for patient vaccination records (18). In addition, IIS can exchange data with health information systems and forecast vaccinations needed by patients that are consistent with ACIP recommendations. Eligible health care providers also have a financial incentive to acquire certified EHR products and demonstrate their meaningful use, defined in part by the Centers for Medicare & Medicaid Services as the data exchange between EHR and IIS (24). There are challenges in the common use of IIS to document vaccinations for adults. First, there are different state regulations regarding consent to retain information in the state or city IIS. Most IIS jurisdictions have the authority to operate an IIS for adults with implied consent and with or without the right to opt out by patients (14). In several IIS jurisdictions, an explicit patient consent is required before adult vaccination information can be submitted to IIS. Second, not all immunization programs have IIS for adults (as mentioned earlier, Rhode Island and Connecticut have IISs for children only). Third, although infrastructure and functional standards describe the operations, data quality, and technology needed by the IIS (9), not all IIS have met all of the functional standards. Multiple factors contribute to low adult vaccination rates. At the individual level, adult patients may not have the awareness or interest in vaccines routinely recommended for adults. Health care providers for adults have a myriad of competing clinical priorities that they feel take precedence over vaccinations and are challenged by coding and billing processes and perceived inadequate payments associated with vaccination services (25–30). At the systems level, health care providers have difficulties ascertaining which vaccines their adult patients need because of incomplete vaccination records, and their EHRs may not be able to systematically assess vaccination records from IISs. Health care systems and providers and immunization programs continue to collaborate to automate bidirectional flow of vaccination data between EHRs and IIS. Plans for IIS include immunization programs continuing to onboard adult vaccination service providers into IIS and automate EHRs to submit and import vaccination data, continuing to develop up-to-date clinical decision-support tools that interface between EHRs and IIS to forecast vaccination needs of adult patients, and sharing adult vaccination data securely and efficiently (13). In addition to developing vaccination procedural coding manuals to help health care providers administer vaccines to their adult patients (31, 33), the American College of Physicians, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists, among other organizations, promote the use of IIS to document and manage adult vaccination records. Consistent use of IIS by health care providers will improve clinical and preventive health services delivery and reduce the burden of illnesses, hospitalizations, and mortality associated with vaccine-preventable diseases among adults. Appendix Recommendations for routine use of vaccines in children, adolescents, and adults are developed by the Advisory Committee on Immunization Practices (ACIP). ACIP is chartered as a federal advisory committee to provide expert external advice and guidance to the Director of the Centers for Disease Control and Prevention (CDC) on the use of vaccines and related agents to control vaccine-preventable diseases in the civilian population of the United States. Recommendations for routine use of vaccines in children and adolescents are harmonized to the greatest extent possible with recommendations made by the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG). Recommendations for routine use of vaccines in adults are harmonized with recommendations of AAFP, ACOG, the American College of Physicians (ACP), and the American College of Nurse-Midwives (ACNM). ACIP recommendations adopted by the CDC Director become agency guidelines on the date published in the Morbidity and Mortality Weekly Report (MMWR). Additional information on ACIP is available at www.cdc.gov/vaccines/acip. Members of the ACIP Nancy Bennett, MD, MS, University of Rochester, Rochester, New York (Chair); Amanda Cohn, MD, Centers for Disease Control and Prevention, Atlanta, Georgia (Executive Secretary); Robert L. Atmar, MD, Baylor University, Houston, Texas; Edward Belongia, MD, Marshfield Clinic Research Foundation, Marshfield, Wisconsin; Echezona Ezeanolue, MD, MPH, University of Nevada, Las Vegas, Nevada; Paul Hunter, MD, University of Wisconsin, Madison, Wisconsin; Allison Kempe, MD, MPH, University of Colorado, Denver, Colorado; Grace M. Lee, MD, MPH, Lucile Packard Children's Hospital, Stanford, California; Kelly Moore, MD, MPH, Tennessee Department of Health, Nashville, Tennessee; Cynthia Pellegrini, March of Dimes, Washington, DC; Arthur L. Reingold, MD, University of California, Berkeley, California; Laura E. Riley, MD, Harvard University, Cambridge, Massachusetts; José R. Romero, MD, University of Arkansas, Little Rock, Arkansas; David Stephens, MD, Emory University, Atlanta, Georgia; Peter Szilagyi, MD, MPH, University of California, Los Angeles, California; Emmanuel (Chip) Walter Jr., MD, MPH, Duke University, Durham, North Carolina. A list of current ACIP members is available at www.cdc.gov/vaccines/acip/committee/members.html. ACIP Adult Immunization Work Group Work Group Chair: Laura E. Riley, MD, Cambridge, Massachusetts. Work Group Members: John Epling, MD, MSEd, Syracuse, New York; Sandra Fryhofer, MD, Atlanta, Georgia; Robert H. Hopkins Jr., MD, Little Rock, Arkansas; Paul Hunter, MD, Madison, Wisconsin; Jane Kim, MD, Durham, North Carolina; Laura Pinkston Koenigs, MD, Springfield, Massachusetts; Maria Lanzi, ANP, MPH, Philadelphia, Pennsylvania; Marie-Michele Leger, MPH, PA-C, Alexandria, Virginia; Susan M. Lett, MD, Boston, Massachusetts; Gregory Poland, MD, Rochester, Minnesota; Joni Reynolds, MPH, Denver, Colorado; Charles Rittle, DNP, MPH, RN, Pittsburgh, Pennsylvania; William Schaffner, MD, Nashville, Tennessee; Kenneth Schmader, MD, Durham, North Carolina; Rhoda Sperling, MD, New York, New York; David Weber, MD, MPH, Chapel Hill, North Carolina. Work Group Contributors: Anna Acosta, MD, Atlanta, Georgia; Mitesh Desai, MD, MPH, Atlanta, Georgia; Kathleen Dooling, MD, MPH, Atlanta, Georgia; Lisa Grohskopf, MD, MPH, Atlanta, Georgia; Susan Hairiri, PhD, MPH, Atlanta, Georgia; Lauri Markowitz, MD, Atlanta, Georgia; Sarah Meyer, MD, MPH, Atlanta, Georgia; Sara Oliver, MD, MSPH, Atlanta, Georgia; Tamara Pilishvili, MPH, Atlanta, Georgia; Candice Robinson, MD, MPH, Atlanta, Georgia; Sarah Schillie, MD, Atlanta, Georgia; Raymond A. Strikas, MD, MPH, Atlanta, Georgia; Walter W. Williams, MD, MPH, Atlanta, Georgia. Work Group Consultants: Carolyn Bridges, MD, Boise, Idaho; Tamera Coyne-Beasley, MD, MPH, Chapel Hill, North Carolina; Kathleen Harriman, PhD, MPH, RN, Richmond, California; Molly Howell, MPH, Bismarck, North Dakota; Diane Peterson, Saint Paul, Minnesota; Angela Shen, ScD, MPH, Washington, DC; Litjen Tan, PhD, Chicago, Illinois. Work Group Secretariat: David K. Kim, MD, MA, Atlanta, Georgia. 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Accessed at www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html on 15 December 2017. Hurley LP Lindley MC Allison MA Crane LA Brtnikova M Beaty BL et al Primary care physicians' perspective on financial issues and adult immunization in the Era of the Affordable Care Act. Vaccine 2017 35 647 654 PubMed CrossRef PubMed Hurley LP Bridges CB Harpaz R Allison MA O'Leary ST Crane LA et al U.S. physicians' perspective of adult vaccine delivery. Ann Intern Med 2014 160 161 . CrossRef PubMed Bridges CB Hurley LP Williams WW Ramakrishnan A Dean AK Groom AV Meeting the challenges of immunizing adults. Am J Prev Med 2015 49 S455 64 PubMed CrossRef PubMed Johnson DR Nichol KL Lipczynski K Barriers to adult immunization. Am J Med 2008 121 S28 35 PubMed CrossRef PubMed Lu PJ O'Halloran A Williams WW Impact of health insurance status on vaccination coverage among adult populations. 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Should This Patient Receive Hormone Therapy for Her Menopausal Symptoms?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-06 Eileen E. Reynolds, Carol Bates, Martha Richardson, Risa B. Burns
Hormone therapy (HT) was widely prescribed in the 1980s and 1990s and has been controversial since the initial results of the Women's Health Initiative (WHI) trial in the early 2000s suggested that it increased risk for breast cancer and coronary heart disease and did not prolong life. However, more recent data and reexamination of the WHI results suggest that HT is safe and effective for many women when used around the time of menopause. Two experts debate the 2017 Hormone Therapy Position Statement of The North American Menopause Society, which recommends HT as first-line treatment of vasomotor symptoms, and apply it to the care of Ms. R, a 52-year-old woman with severe hot flashes, sleep disturbance, and irritability.
Prognostic Accuracy of the Quick Sequential Organ Failure Assessment for Mortality in Patients With Suspected Infection: A Systematic Review and Meta-analysis Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-06 Shannon M. Fernando, Alexandre Tran, Monica Taljaard, Wei Cheng, Bram Rochwerg, Andrew J.E. Seely, Jeffrey J. Perry
Background: The quick Sequential Organ Failure Assessment (qSOFA) has been proposed for prediction of mortality in patients with suspected infection. Purpose: To summarize and compare the prognostic accuracy of qSOFA and the systemic inflammatory response syndrome (SIRS) criteria for prediction of mortality in adult patients with suspected infection. Data Sources: Four databases from inception through November 2017. Study Selection: English-language studies using qSOFA for prediction of mortality (in-hospital, 28-day, or 30-day) in adult patients with suspected infection in the intensive care unit (ICU), emergency department (ED), or hospital wards. Data Extraction: Two investigators independently extracted data and assessed study quality using standard criteria. Data Synthesis: Thirty-eight studies were included (n = 385 333). qSOFA was associated with a pooled sensitivity of 60.8% (95% CI, 51.4% to 69.4%) and a pooled specificity of 72.0% (CI, 63.4% to 79.2%) for mortality. The SIRS criteria were associated with a pooled sensitivity of 88.1% (CI, 82.3% to 92.1%) and a pooled specificity of 25.8% (CI, 17.1% to 36.9%). The pooled sensitivity of qSOFA was higher in the ICU population (87.2% [CI, 75.8% to 93.7%]) than the non-ICU population (51.2% [CI, 43.6% to 58.7%]). The pooled specificity of qSOFA was higher in the non-ICU population (79.6% [CI, 73.3% to 84.7%]) than the ICU population (33.3% [CI, 23.8% to 44.4%]). Limitation: Potential risk of bias in included studies due to qSOFA interpretation and patient selection. Conclusion: qSOFA had poor sensitivity and moderate specificity for short-term mortality. The SIRS criteria had sensitivity superior to that of qSOFA, supporting their use for screening of patients and as a prompt for treatment initiation. Primary Funding Source: Canadian Association of Emergency Physicians. (PROSPERO: CRD42017075964)
Effect of Hot Tea Consumption and Its Interactions With Alcohol and Tobacco Use on the Risk for Esophageal Cancer: A Population-Based Cohort Study Ann. Intern. Med. (IF 17.135) Pub Date : 2018-02-06 Canqing Yu, Haijing Tang, Yu Guo, Zheng Bian, Ling Yang, Yiping Chen, Aiyu Tang, Xue Zhou, Xu Yang, Junshi Chen, Zhengming Chen, Jun Lv, Liming Li
Background: Although consumption of tea at high-temperatures has been suggested as a risk factor for esophageal cancer, an association has not been observed consistently, and whether any relationship is independent of alcohol and tobacco exposure has not been evaluated. Objective: To examine whether high-temperature tea drinking, along with the established risk factors of alcohol consumption and smoking, is associated with esophageal cancer risk. Design: China Kadoorie Biobank, a prospective cohort study established during 2004 to 2008. Setting: 10 areas across China. Participants: 456 155 persons aged 30 to 79 years. Those who had cancer at baseline or who reduced consumption of tea, alcohol, or tobacco before baseline were excluded. Measurements: The usual temperature at which tea was consumed, other tea consumption metrics, and lifestyle behaviors were self-reported once, at baseline. Outcome was esophageal cancer incidence up to 2015. Results: During a median follow-up of 9.2 years, 1731 incident esophageal cancer cases were documented. High-temperature tea drinking combined with either alcohol consumption or smoking was associated with a greater risk for esophageal cancer than hot tea drinking alone. Compared with participants who drank tea less than weekly and consumed fewer than 15 g of alcohol daily, those who drank burning-hot tea and 15 g or more of alcohol daily had the greatest risk for esophageal cancer (hazard ratio [HR], 5.00 [95% CI, 3.64 to 6.88]). Likewise, the HR for current smokers who drank burning-hot tea daily was 2.03 (CI, 1.55 to 2.67). Limitation: Tea consumption was self-reported once, at baseline, leading to potential nondifferential misclassification and attenuation of the association. Conclusion: Drinking tea at high temperatures is associated with an increased risk for esophageal cancer when combined with excessive alcohol or tobacco use. Primary Funding Source: National Natural Science Foundation of China and National Key Research and Development Program.
Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-14 Michelle M. Graham, Daniel I. Sessler, Joel L. Parlow, Bruce M. Biccard, Gordon Guyatt, Kate Leslie, Matthew T.V. Chan, Christian S. Meyhoff, Denis Xavier, Alben Sigamani, Priya A. Kumar, Marko Mrkobrada, Deborah J. Cook, Vikas Tandon, Jesus Alvarez-Garcia, Juan Carlos Villar, Thomas W. Painter, Giovanni Landoni, Edith Fleischmann, Andre Lamy, Richard Whitlock, Yannick Le Manach, Meylin Aphang-Lam, Juan P. Cata, Peggy Gao, Nicolaas C.S. Terblanche, Pamidimukkala V. Ramana, Kim A. Jamieson, Amal Bessissow, Gabriela R. Mendoza, Silvia Ramirez, Pierre A. Diemunsch, Salim Yusuf, P.J. Devereaux
Background: Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery. Objective: To evaluate benefits and harms of perioperative aspirin in patients with prior PCI. Design: Nonprespecified subgroup analysis of a multicenter factorial trial. Computerized Internet randomization was done between 2010 and 2013. Patients, clinicians, data collectors, and outcome adjudicators were blinded to treatment assignment. (ClinicalTrials.gov: NCT01082874) Setting: 135 centers in 23 countries. Patients: Adults aged 45 years or older who had or were at risk for atherosclerotic disease and were having noncardiac surgery. Exclusions were placement of a bare-metal stent within 6 weeks, placement of a drug-eluting stent within 1 year, or receipt of nonstudy aspirin within 72 hours before surgery. Intervention: Aspirin therapy (overall trial, n = 4998; subgroup, n = 234) or placebo (overall trial, n = 5012; subgroup, n = 236) initiated within 4 hours before surgery and continued throughout the perioperative period. Of the 470 subgroup patients, 99.9% completed follow-up. Measurements: The 30-day primary outcome was death or nonfatal myocardial infarction; bleeding was a secondary outcome. Results: In patients with prior PCI, aspirin reduced the risk for the primary outcome (absolute risk reduction, 5.5% [95% CI, 0.4% to 10.5%]; hazard ratio [HR], 0.50 [CI, 0.26 to 0.95]; P for interaction = 0.036) and for myocardial infarction (absolute risk reduction, 5.9% [CI, 1.0% to 10.8%]; HR, 0.44 [CI, 0.22 to 0.87]; P for interaction = 0.021). The effect on the composite of major and life-threatening bleeding in patients with prior PCI was uncertain (absolute risk increase, 1.3% [CI, −2.6% to 5.2%]). In the overall population, aspirin increased the risk for major bleeding (absolute risk increase, 0.8% [CI, 0.1% to 1.6%]; HR, 1.22 [CI, 1.01 to 1.48]; P for interaction = 0.50). Limitation: Nonprespecified subgroup analysis with small sample. Conclusion: Perioperative aspirin may be more likely to benefit rather than harm patients with prior PCI. Primary Funding Source: Canadian Institutes of Health Research.
The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-28 Eric T. Roberts, Alan M. Zaslavsky, J. Michael McWilliams
Background: When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average. Objective: To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients. Design: Exploiting the phase-in of the VM on the basis of practice size, regression discontinuity analysis and 2014 Medicare claims were used to estimate differences in practice performance associated with exposure of practices with 100 or more clinicians to full VM incentives (bonuses and penalties) and exposure of practices with 10 or more clinicians to partial incentives (bonuses only). Analyses were repeated with 2015 claims to estimate performance differences associated with a second year of exposure above the threshold of 100 or more clinicians. Performance differences were assessed between practices serving higher- and those serving lower-risk patients after standard Medicare adjustments versus adjustment for additional patient characteristics. Setting: Fee-for-service Medicare. Patients: Random 20% sample of beneficiaries. Measurements: Hospitalization for ambulatory care–sensitive conditions, all-cause 30-day readmissions, Medicare spending, and mortality. Results: No statistically significant discontinuities were found at the threshold of 10 or more or 100 or more clinicians in the relationship between practice size and performance on quality or spending measures in either year. Adjustment for additional patient characteristics narrowed performance differences by 9.2% to 67.9% between practices in the highest and those in the lowest quartile of Medicaid patients and Hierarchical Condition Category scores. Limitation: Observational design and administrative data. Conclusion: The VM was not associated with differences in performance on program measures. Performance differences between practices serving higher- and those serving lower-risk patients were affected considerably by additional adjustments, suggesting a potential for Medicare's pay-for-performance programs to exacerbate health care disparities. Primary Funding Source: The Laura and John Arnold Foundation and National Institute on Aging.
Provider Types and Outcomes in Obstructive Sleep Apnea Case Finding and Treatment: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-30 Ken M. Kunisaki, Nancy Greer, Wajahat Khalil, Erin Koffel, Eva Koeller, Roderick MacDonald, Timothy J. Wilt
Background: Obstructive sleep apnea (OSA) diagnosis and care models rely on sleep specialist physicians (SSPs) and can be expensive and inefficient. Purpose: To assess OSA case-finding accuracy and comparative effectiveness of care by non–sleep specialists (NSSs) and SSPs. Data Sources: MEDLINE and CINAHL from January 2000 through July 2017. Study Selection: English-language trials or observational studies comparing case finding or care by SSPs versus providers not specifically trained as SSPs (NSSs) for adults with suspected or diagnosed OSA. Data Extraction: One investigator extracted data and assessed risk of bias and strength of evidence, with confirmation by a second investigator. Primary outcomes were patient-centered (mortality, access to care, quality of life, patient satisfaction, adherence, symptom scores, and adverse events). Intermediate outcomes included resource use, costs, time to initiation of treatment, and case finding. Data Synthesis: Four observational studies (n = 580; mean age, 52 years; 77% male) reported good agreement between NSSs and SSPs on appropriate diagnostic testing and classification of OSA severity (low-strength evidence). Five randomized trials and 3 observational studies (n = 1515; mean age, 52 years; 68% male) found that care provided by NSSs and SSPs resulted in similar quality of life, adherence, and symptom scores (low-strength evidence). Evidence was insufficient for access to care and adverse events. Limitations: Many outcomes were reported infrequently or not at all. Many NSSs had extensive training or experience in sleep medicine, which limits generalizability of findings to providers with less experience. Conclusion: Care by NSSs and SSPs resulted in similar outcomes in adults with known or suspected OSA. Studies are needed to determine care model implementation and reproducibility of results in nonacademic settings and among less experienced NSSs. Primary Funding Source: Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO: CRD42016036810 [full Veterans Affairs Evidence-based Synthesis Program report])
Mid- and Long-Term Health Risks in Living Kidney Donors: A Systematic Review and Meta-analysis Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-30 Linda M. O'Keeffe, Anna Ramond, Clare Oliver-Williams, Peter Willeit, Ellie Paige, Patrick Trotter, Jonathan Evans, Jonas Wadström, Michael Nicholson, Dave Collett, Emanuele Di Angelantonio
Background: Long-term health risks for adults who donate kidneys are unclear. Purpose: To summarize evidence about mid- and long-term health risks associated with living kidney donation in adults. Data Sources: PubMed, Embase, Scopus, and PsycINFO without language restriction from April 1964 to July 2017. Study Selection: Observational studies with at least 1 year of follow-up that compared health outcomes in adult living kidney donors versus nondonor populations. Data Extraction: Two investigators independently extracted study data and assessed study quality. Data Synthesis: 52 studies, comprising 118 426 living kidney donors and 117 656 nondonors, were included. Average follow-up was 1 to 24 years. No evidence suggested higher risk for all-cause mortality, cardiovascular disease, hypertension, type 2 diabetes, or adverse psychosocial health outcomes in living kidney donors than in nondonor populations. Donors had higher diastolic blood pressure, lower estimated glomerular filtration rates, and higher risk for end-stage renal disease (ESRD) (relative risk [RR], 8.83 [95% CI, 1.02 to 20.93]) and preeclampsia in female donors (RR, 2.12 [CI, 1.06 to 4.27]). Despite the increased RR, donors had low absolute risk for ESRD (incidence rate, 0.5 event [CI, 0.1 to 4.9 events] per 1000 person-years) and preeclampsia (incidence rate, 5.9 events [CI, 2.9 to 8.9 events] per 100 pregnancies). Limitation: Generalizability was limited by selected control populations, few studies reported pregnancy-related outcomes, and few studies were from low- and middle-income countries. Conclusion: Although living kidney donation is associated with higher RRs for ESRD and preeclampsia, the absolute risk for these outcomes remains low. Compared with nondonor populations, living kidney donors have no increased risk for other major chronic diseases, such as type 2 diabetes, or for adverse psychosocial outcomes. Primary Funding Source: National Health Service Blood and Transplant and National Institute for Health Research. (PROSPERO: CRD42017072284)
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-23 Robert M. Carey, Paul K. Whelton
Description: In November 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) released a clinical practice guideline for the prevention, detection, evaluation, and treatment of high blood pressure (BP) in adults. This article summarizes the major recommendations. Methods: In 2014, the ACC and the AHA appointed a multidisciplinary committee to update previous reports of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The committee reviewed literature and commissioned systematic reviews and meta-analyses on out-of-office BP monitoring, the optimal target for BP lowering, the comparative benefits and harms of different classes of antihypertensive agents, and the comparative benefits and harms of initiating therapy with a single antihypertensive agent or a combination of 2 agents. Recommendations: This article summarizes key recommendations in the following areas: BP classification, BP measurement, screening for secondary hypertension, nonpharmacologic therapy, BP thresholds and cardiac risk estimation to guide drug treatment, treatment goals (general and for patients with diabetes mellitus, chronic kidney disease, and advanced age), choice of initial drug therapy, resistant hypertension, and strategies to improve hypertension control.
Associations Between Marijuana Use and Cardiovascular Risk Factors and Outcomes: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-23 Divya Ravi, Mehrnaz Ghasemiesfe, Deborah Korenstein, Thomas Cascino, Salomeh Keyhani
Background: Marijuana use is increasing in the United States, and its effect on cardiovascular health is unknown. Purpose: To review harms and benefits of marijuana use in relation to cardiovascular risk factors and clinical outcomes. Data Sources: PubMed, MEDLINE, EMBASE, PsycINFO, and the Cochrane Library between 1 January 1975 and 30 September 2017. Study Selection: Observational studies that were published in English, enrolled adults using any form of marijuana, and reported on vascular risk factors (hyperglycemia, diabetes, dyslipidemia, and obesity) or on outcomes (stroke, myocardial infarction, cardiovascular mortality, and all-cause mortality in cardiovascular cohorts). Data Extraction: Study characteristics and quality were assessed by 4 reviewers independently; strength of evidence for each outcome was graded by consensus. Data Synthesis: 13 and 11 studies examined associations between marijuana use and cardiovascular risk factors and clinical outcomes, respectively. Although 6 studies suggested a metabolic benefit from marijuana use, they were based on cross-sectional designs and were not supported by prospective studies. Evidence examining the effect of marijuana on diabetes, dyslipidemia, acute myocardial infarction, stroke, or cardiovascular and all-cause mortality was insufficient. Although the current literature includes several long-term prospective studies, they are limited by recall bias, inadequate exposure assessment, minimal marijuana exposure, and a predominance of low-risk cohorts. Limitation: Poor- or moderate-quality data, inadequate assessment of marijuana exposure and minimal exposure in the populations studied, and variation in study design. Conclusion: Evidence examining the effect of marijuana on cardiovascular risk factors and outcomes, including stroke and myocardial infarction, is insufficient. Primary Funding Source: National Heart, Lung, and Blood Institute. (PROSPERO: CRD42016051297)
Antithyroid Drugs and Congenital Malformations: A Nationwide Korean Cohort Study Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-23 Gi Hyeon Seo, Tae Hyuk Kim, Jae Hoon Chung
Background: Untreated or insufficiently treated Graves disease in pregnancy may pose risks to both mother and fetus. Antithyroid drugs (ATDs) are the treatment mainstay, but the potential teratogenic effect of these drugs has prompted clinicians to question the safe management of this vulnerable population. Objective: To examine the association between maternal prescriptions for ATDs and congenital malformations in live births. Design: Nationwide cohort study. Setting: Korean National Health Insurance database. Participants: A cohort of 2 886 970 completed pregnancies linked to live-born infants in 2 210 253 women between 2008 and 2014. Intervention: Maternal prescriptions for ATDs in the first trimester. Measurements: The risk for overall and organ-specific congenital malformations in offspring, with logistic regression models used to control for potential confounders. Results: 12 891 pregnancies (0.45%) were exposed to ATDs during the first trimester. The prevalence of malformations in exposed offspring was 7.27%, compared with 5.94% in offspring of women who were not prescribed ATDs during pregnancy (P < 0.001) (adjusted odds ratio, 1.19 [95% CI, 1.12 to 1.28]). Absolute increases in the prevalence of congenital malformations per 1000 live births were 8.81 cases (CI, 3.92 to 13.70 cases) for propylthiouracil alone, 17.05 cases (CI, 1.94 to 32.15 cases) for methimazole (MMI) alone, and 16.53 cases (CI, 4.73 to 28.32 cases) for propylthiouracil and MMI, compared with pregnancies without ATD prescriptions. In the MMI group, a high cumulative dose (>495 mg) during the first trimester was associated with an increased risk for malformations compared with a low dose (1 to 126 mg) (adjusted odds ratio, 1.87 [CI, 1.06 to 3.30]). Limitation: The study used a prescription claims database to assess ATD exposure. Conclusion: Exposure to ATDs during the first trimester was associated with increased risk for congenital malformations, particularly for pregnancies in which women received prescriptions for MMI or both ATDs. Primary Funding Source: None.
Annals for Hospitalists - 16 January 2018 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-16 David H. Wesorick, Vineet Chopra
Inpatient Notes Modernizing Rounds—Why It's Time to Redesign Our Hospital Practice —Jason Stein, MD, and Susan Shapiro, PhD, RN How can we elevate the quality and efficiency of inpatient care? The authors of this month's Inpatient Notes explain why it is time for radical, disruptive change in how we organize our patients, and how we round on them. Highlights of Recent Articles From Annals of Internal Medicine Diagnosis of Venous Thromboembolism: 20 Years of Progress Ann Intern Med. 2018;168:131-140. Published 9 January 2018. doi:10.7326/M17-0291 This article analyzed 29 systematic reviews/meta-analyses, 7 randomized controlled trials, and 22 prospective studies related to the diagnosis of venous thromboembolism and summarizes the optimal diagnostic approach. Key points for hospitalists include: The diagnosis of suspected pulmonary embolism (PE) is best approached by using an algorithm that includes the estimation of pretest probability, the selective use of D-dimer testing (in patients with low or moderate pretest probability), and the use of appropriate imaging tests (which can include lower-extremity compression ultrasonography, computed tomography (CT) pulmonary angiography, or ventilation–perfusion scanning). The authors provide a diagnostic algorithm incorporating these tests and strategies. The use of pretest probability tools can help clinicians decide when imaging is necessary, but it can also be helpful in detecting false-positive imaging results. For example, the posttest probability of PE in a patient with low pretest probability and a positive CT pulmonary angiogram is only 30%. Positive scans in these patients should be reviewed with an imaging specialist. Pretest probability tools have not been well-studied in hospitalized patients, and D-dimer testing is not useful in this population. Therefore, the authors recommend that the evaluation of hospitalized patients with suspected PE forgo the algorithmic approach and move directly to imaging. Readmissions After Revascularization Procedures for Peripheral Arterial Disease: A Nationwide Cohort Study Ann Intern Med. 2017;168:93-99. Published 5 December 2017. doi:10.7326/M17-1058 This retrospective cohort study examined data from 61 969 patients who were discharged after peripheral arterial revascularization. The 30-day nonelective readmission rate in this cohort was 17.6%. Key points for hospitalists include: Patients undergoing peripheral arterial revascularization have a very high 30-day readmission rate. Although procedural complications account for the largest segment of these readmissions (28%), sepsis (8.3%), diabetes (7.5%), and congestive heart failure (4.4%) are also important causes of readmission. Readmitted patients were more likely to have comorbid conditions, such as chronic limb ischemia, obesity, hypertension, congestive heart failure, diabetes, or renal disease. The Latest Highlights From ACP Journal Club Should patients with unprovoked venous thromboembolism (VTE) undergo extensive cancer screening? Review: In patients with a first VTE, extended testing for undiagnosed cancer does not reduce mortality Ann Intern Med. 2017;167:JC50. doi:10.7326/ACPJC-2017-167-12-064 This systematic review examined 4 randomized controlled trials (n = 1644) that compared standard testing with extensive testing (including CT of the abdomen and pelvis in 1 trial, and positron emission tomography scanning in another) in patients who presented with unprovoked VTE. Although more early cancer was discovered in the extensive testing group, no difference in cancer-related or all-cause mortality between groups was found after 2 years of follow-up. Despite the previously demonstrated relationship between VTE and cancer, these data do not support aggressive cancer screening in patients with unprovoked VTE. Is triple antithrombotic therapy the optimal approach for patients with atrial fibrillation having percutaneous coronary intervention? After PCI in AF, dual antithrombotic therapy with dabigatran reduced bleeding compared with triple therapy Ann Intern Med. 2017;167:JC70. doi:10.7326/ACPJC-2017-167-12-070 In this randomized controlled trial (n = 2725), patients with atrial fibrillation having percutaneous coronary intervention were randomly assigned to receive triple therapy (aspirin, clopidogrel, and warfarin) or dual therapy with dabigatran (either 110 mg or 150 mg twice daily) and clopidogrel. There was no difference between groups in the rate of stent thrombosis or the composite outcome (myocardial infarction, stroke, systemic embolism, death, or unplanned revascularization). However, among patients receiving dual therapy, there was a statistically significant reduction in the risk for bleeding. Although the trial was not adequately powered to rule out a small difference in stent thrombosis between groups, it does add to mounting evidence that dual therapy may be safer than triple therapy in these patients. Sign up here to have Annals for Hospitalists delivered to your inbox each month.
Annals for Educators - 16 January 2018 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-16 Darren B. Taichman
Clinical Practice Points Use of Immune Checkpoint Inhibitors in the Treatment of Patients With Cancer and Preexisting Autoimmune Disease. A Systematic Review This systematic review describes adverse events in patients with cancer and concomitant autoimmune disease who received cancer immunotherapy with checkpoint inhibitors (CPIs). Use this review to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners what CPIs are. How do they work as antitumor agents? For what types of cancer have they been shown to be successful? Invite an oncologist to join your discussion. Why have patients with autoimmune disease been excluded from clinical trials of CPIs? Why might the mechanism of action of CPIs lead to autoimmune adverse events? Review the results of this study. What are the limitations of the available data? Use the authors' discussion and the accompanying editorial to help answer this question. How are the observational reports identified in this review helpful for clinical practice and further research, despite their weaknesses? Comparison of Five Major Guidelines for Statin Use in Primary Prevention in a Contemporary General Population Five professional organizations in Europe and North America have published guidelines for using statins to prevent atherosclerotic cardiovascular disease. Application of the different guidelines to a single population aged 40 to 75 years would result in as few as 15% or as many as 44% of participants receiving statins. This study estimated how many cardiovascular events would be prevented using each guideline. Use this paper to: Ask your learners how they decide which patients should use statins for primary prevention of cardiovascular disease. What do the guidelines recommend? Which ones do your learners know about? Review Table 1, which summarizes the approaches taken by each of the 5 major guidelines. What are the key differences? Ask your learners why following each of the guidelines results in a different number of patients recommended for statin use in the population modeled here and why the number of cardiovascular events differs. Why do guideline groups issue different recommendations despite using largely the same evidence? Use the accompanying editorial to help frame your discussion. What approach do your learners intend to follow? Why? What are the risks and benefits of their planned approaches? Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients. A Systematic Review and Meta-analysis This meta-analysis of data from 100 trials examines the comparative effectiveness of 8 implementation strategies for blood pressure control in adults with hypertension. Use this review to: Ask your learners what strategies are used in their practices to help patients reach blood pressure treatment goals. Review the list of implementation strategies in Table 1. Which ones are used at your center? Before reviewing this study's results, ask your learners how well they think each of the listed strategies performs. Review the results. Are your learners surprised? Why do your learners think certain strategies work better than others? If team-based approaches to blood pressure control are used at your institution's outpatient practices, who is involved? Who monitors performance in your practice? How is performance assessed? Invite a quality improvement officer to join your discussion. Why do your learners think that involvement of nonphysician team members was found to be useful? What are the potential benefits, as well as barriers to their involvement? Use the accompanying editorial to help frame your discussion. Log on and answer the accompanying questions to earn CME/MOC credit for yourself! Diagnosis of Venous Thromboembolism: 20 Years of Progress This special article details state-of-the-art algorithms for diagnosing deep venous thrombosis (DVT) and pulmonary embolism (PE) in adults, including pregnant women. Use this paper to: Ask your learners why establishing a pretest clinical probability of either DVT or PE is important. How does the pretest probability affect the choice of test and the interpretation of results? How do your learners assess pretest probability? Do they do so in a systematic manner? What is the PERC tool, and when is it useful? Review the algorithms for evaluation of potential DVT and PE. Are these the approaches followed by your learners? Why or why not? What imaging tests should be used for suspected DVT or PE in a pregnant patient? Does a V/Q or CT angiographic study expose the patient or fetus to more radiation? Getting Credit for What You Do By simply logging on when you click through to see the papers highlighted in this alert, you'll be eligible to claim point-of-care CME and MOC points. Logging on at the top right of the Web site takes seconds. Papers you look at when logged in will be recorded, allowing you to claim CME/MOC credit later by answering 2 simple questions about how you used the content. Give yourself the credit you deserve! MKSAP 17 Question A 55-year-old woman is evaluated in the emergency department for a 3-day history of diarrhea. She reports seven to eight stools daily without vomiting. She also notes abdominal cramping without vomiting and has been able to maintain adequate fluid intake. Medical history is significant for metastatic malignant melanoma, for which she recently completed the third of four planned doses of ipilimumab therapy. She has no history of inflammatory bowel disease, recent antibiotic use, recent travel, or consumption of uncooked foods. The remainder of the medical history is noncontributory, and she takes no other medications. On physical examination, temperature is 37.5 °C (99.5 °F), blood pressure is 125/85 mm Hg, pulse rate is 90/min without orthostatic changes, and respiration rate is 14/min. The abdomen is soft and nontender with increased bowel sounds. The remainder of the physical examination is normal. Laboratory studies: Hemoglobin 12.2 g/dL (122 g/L) Leukocyte count 9300/μL (9.3 × 109/L) with normal differential Alanine aminotransferase 120 U/L Aspartate aminotransferase 160 U/L Creatinine 1.2 mg/dL (106.1 μmol/L) Fecal occult blood test Negative Hemoglobin 12.2 g/dL (122 g/L) Leukocyte count 9300/μL (9.3 × 109/L) with normal differential Alanine aminotransferase 120 U/L Aspartate aminotransferase 160 U/L Creatinine 1.2 mg/dL (106.1 μmol/L) Fecal occult blood test Negative A chest radiograph is normal and abdominal films show nondilated bowel loops with no free air. In addition to discontinuing the ipilimumab and providing supportive care, which of the following is the most appropriate next step in treatment? A. Broad-spectrum intravenous antibiotics B. Granulocyte-macrophage colony-stimulating factor C. High-dose intravenous glucocorticoids D. Observation Correct Answer C. High-dose intravenous glucocorticoids Educational Objective Manage ipilimumab-induced toxicity. Critique Initiation of high-dose intravenous glucocorticoids and aggressive supportive care in addition to discontinuing the offending medication is the most appropriate treatment for this patient with ipilimumab toxicity with severe diarrhea and evidence of autoimmune hepatitis. Ipilimumab is a new class of antineoplastic therapy that inhibits the function of T-cell checkpoint receptors (ipilimumab or PD-1 and PD-L1 inhibitors), thereby enhancing the function of the immune system and inducing remissions in patients with various solid tumors, particularly metastatic melanoma. However, T-cell checkpoint inhibitors also can cause many potentially permanent and life-threatening organ toxicities that are autoimmune-mediated based on their enhancement of immune function. These include dermatologic (rash, mucositis), gastrointestinal (diarrhea, colitis), liver (autoimmune hepatitis), and endocrine (hypothalamic/pituitary, thyroid, and adrenal insufficiency). Other organ involvement (eye, kidney, hematologic, pulmonary, and neurologic) has also been reported. Because the toxicity results from triggering an exaggerated immune response, treatment of these toxicities involves removing the causative agent and providing immunosuppression, preferably with high-dose glucocorticoids due to their nonspecific immune-suppressing effects and rapid onset of action. Recognition of the autoimmune effect of the treatment is critical since the autoimmune-triggered toxicity from this class of medications can be fatal if immunosuppressive therapy is delayed. Because the mechanism of toxicity is not directly related to leukopenia and this patient has a normal leukocyte count with no objective evidence of infection, broad-spectrum antibiotics are not indicated, and delayed recognition of the drug-related syndrome from treatment of possible bacterial infection could be detrimental. Similarly, because the toxicity of T-cell checkpoint inhibitors is not due to leukopenia, treatment with growth factors, such as granulocyte-macrophage colony-stimulating factor, does not have a role in either the prevention or treatment of complications associated with this class of drugs. Because rapid immunosuppression may reverse the severe autoimmune reactions triggered by ipilimumab, discontinuation of the medication and supportive care alone is inadequate therapy for this patient. Key Point Patients with acute ipilimumab toxicity should receive fluid replacement and immediate glucocorticoid therapy to reverse the damage this agent can cause; delay in treatment can be fatal. Bibliography Weber JS, O’Day S, Urba W, et al. Phase I/II study of ipilimumab for patients with metastatic melanoma. J Clin Oncol. 2008 Dec 20;26(36):5950-6. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Correction: Benefits and Harms of Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-16
In Figure 1 of a review (1), the subtotal of cardiac events should be 20 122 as opposed to 1534. This has been corrected in the online version. References Weiss J Freeman M Low A Fu R Kerfoot A Paynter R et al Benefits and harms of intensive blood pressure treatment in adults aged 60 years or older. A systematic review and meta-analysis, Ann Intern Med 2017 166 419 29 CrossRef PubMed
White Blood Cell BRCA1 Promoter Methylation Status and Ovarian Cancer Risk Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-16 Per E. Lønning, Elisabet O. Berge, Merete Bjørnslett, Laura Minsaas, Ranjan Chrisanthar, Hildegunn Høberg-Vetti, Cécile Dulary, Florence Busato, Silje Bjørneklett, Christine Eriksen, Reidun Kopperud, Ulrika Axcrona, Ben Davidson, Line Bjørge, D. Gareth Evans, Anthony Howell, Helga B. Salvesen, Imre Janszky, Kristian Hveem, Pål R. Romundstad, Lars J. Vatten, Jörg Tost, Anne Dørum, Stian Knappskog
Background: The role of normal tissue gene promoter methylation in cancer risk is poorly understood. Objective: To assess associations between normal tissue BRCA1 methylation and ovarian cancer risk. Design: 2 case–control (initial and validation) studies. Setting: 2 hospitals in Norway (patients) and a population-based study (control participants). Participants: 934 patients and 1698 control participants in the initial study; 607 patients and 1984 control participants in the validation study. Measurements: All patients had their blood sampled before chemotherapy. White blood cell (WBC) BRCA1 promoter methylation was determined by using methylation-specific quantitative polymerase chain reaction, and the percentage of methylation-positive samples was compared between population control participants and patients with ovarian cancer, including the subgroup with high-grade serous ovarian cancer (HGSOC). Results: In the initial study, BRCA1 methylation was more frequent in patients with ovarian cancer than control participants (6.4% vs. 4.2%; age-adjusted odds ratio [OR], 1.83 [95% CI, 1.27 to 2.63]). Elevated methylation, however, was restricted to patients with HGSOC (9.6%; OR, 2.91 [CI, 1.85 to 4.56]), in contrast to 5.1% and 4.0% of patients with nonserous and low-grade serous ovarian cancer (LGSOC), respectively. These findings were replicated in the validation study (methylation-positive status in 9.1% of patients with HGSOC vs. 4.3% of control participants—OR, 2.22 [CI 1.40 to 3.52]—4.1% of patients with nonserous ovarian cancer, and 2.7% of those with LGSOC). The results were not influenced by tumor burden, storage time, or WBC subfractions. In separate analyses of young women and newborns, BRCA1 methylation was detected in 4.1% (CI, 1.8% to 6.4%) and 7.0% (CI, 5.0% to 9.1%), respectively. Limitations: Patients with ovarian cancer were recruited at the time of diagnosis in a hospital setting. Conclusion: Constitutively normal tissue BRCA1 promoter methylation is positively associated with risk for HGSOC. Primary Funding Source: Norwegian Cancer Society.
Risk for Arterial and Venous Thrombosis in Patients With Myeloproliferative Neoplasms: A Population-Based Cohort Study Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-16 Malin Hultcrantz, Magnus Björkholm, Paul W. Dickman, Ola Landgren, Åsa R. Derolf, Sigurdur Y. Kristinsson, Therese M.L. Andersson
Background: Patients with myeloproliferative neoplasms (MPNs) are reported to be at increased risk for thrombotic events. However, no population-based study has estimated this excess risk compared with matched control participants. Objective: To assess risk for arterial and venous thrombosis in patients with MPNs compared with matched control participants. Design: Matched cohort study. Setting: Population-based setting in Sweden from 1987 to 2009, with follow-up to 2010. Patients: 9429 patients with MPNs and 35 820 matched control participants. Measurements: The primary outcomes were rates of arterial and venous thrombosis. Flexible parametric models were used to calculate hazard ratios (HRs) and cumulative incidence with 95% CIs. Results: The HRs for arterial thrombosis among patients with MPNs compared with control participants at 3 months, 1 year, and 5 years were 3.0 (95% CI, 2.7 to 3.4), 2.0 (CI, 1.8 to 2.2), and 1.5 (CI, 1.4 to 1.6), respectively. The corresponding HRs for venous thrombosis were 9.7 (CI, 7.8 to 12.0), 4.7 (CI, 4.0 to 5.4), and 3.2 (CI, 2.9 to 3.6). The rate was significantly elevated across all age groups and was similar among MPN subtypes. The 5-year cumulative incidence of thrombosis in patients with MPNs showed an initial rapid increase followed by gentler increases during follow-up. The HR for venous thrombosis decreased during more recent calendar periods. Limitation: No information on individual laboratory results or treatment. Conclusion: Patients with MPNs across all age groups have a significantly increased rate of arterial and venous thrombosis compared with matched control participants, with the highest rates at and shortly after diagnosis. Decreases in the rate of venous thrombosis over time likely reflect advances in clinical management. Primary Funding Source: The Cancer Research Foundations of Radiumhemmet, Blodcancerfonden, the Swedish Research Council, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, the Adolf H. Lundin Charitable Foundation, and Memorial Sloan Kettering Cancer Center.
Effect of Physical Activity on Frailty Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-09
What is the problem and what is known about it so far? Frailty is often associated with aging. Older adults who are frail may have muscle weakness, unintended weight loss, and fatigue, and they may need help with activities of daily living (for example, taking a bath or putting on clothing). Some studies suggest that teaching older adults to be more physically active helps improve physical functioning and may help decrease their risk for becoming frail. Why did the researchers do this particular study? The investigators wanted to compare the effects of a long-term exercise program with those of a health education program on the study participants' risk for becoming frail. They also wanted to see whether the benefits of the exercise program on physical functioning differed for participants who were frail at baseline compared with those who were not. Who was studied? 1,635 older adults, aged 70 to 89 years, who were not physically active and had functional limitations. To participate in the study, they had to be able to walk a quarter mile (400 meters) without the help of another person or using a walker. How was the study done? The researchers analyzed data collected for a trial that was completed in 2013. In the trial, the participants were randomly assigned to receive either a structured exercise program or a health education program for about 3 years. A standard definition was used to classify whether the participants were frail. This definition consisted of measurements of the participants' ability to get up from a chair without using their arms, weight loss, and energy level. The researchers saw the participants every 6 months to measure their ability to walk independently. Major mobility disability (MMD) was defined as not being able to walk a quarter mile within 15 minutes without assistance. What did the researchers find? During the follow-up, the risk for becoming frail did not differ between the group that received the exercise intervention and the group that received health education. Compared with health education, the exercise intervention was associated with improvement in the participants' ability to get up from a chair without using their arms. The positive effects of the exercise intervention on the proportion of participants who developed new episodes of MMD or long-term MMD were not affected by whether they were frail at baseline. What were the limitations of the study? The original trial was not designed to answer the question these researchers were asking. What are the implications of the study? A structured exercise program was not associated with a decreased risk for frailty among older adults. However, the beneficial effect of the exercise program on reducing MMD was not affected by whether the participants were frail at baseline.
Diagnosis of Venous Thromboembolism: 20 Years of Progress Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-09 Philip S. Wells, Ryma Ihaddadene, Aiofe Reilly, Melissa Anne Forgie
Many guidelines suggest incorporating clinical assessment, imaging, and D-dimer testing into diagnostic algorithms in patients with suspected deep venous thrombosis (DVT) and pulmonary embolism (PE). This special article reviews the evidence supporting the use of algorithms and their individual components for diagnosis of upper- and lower-extremity DVT and PE in adults, including pregnant women. The authors identified evidence through several electronic database searches to April 2017, evaluated the robustness of selected evidence, assessed whether diagnostic approaches that do not use algorithms are acceptable, and identified knowledge gaps that require further research.
Percutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysis Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-09 Salvatore De Rosa, Horst Sievert, Jolanda Sabatino, Alberto Polimeni, Sabato Sorrentino, Ciro Indolfi
Background: New evidence emerged recently regarding the percutaneous closure of patent foramen ovale (PFO) to prevent recurrent stroke in patients with cryptogenic stroke. Purpose: To compare risks for recurrent cerebrovascular events in adults with PFO and cryptogenic stroke who underwent PFO closure versus those who received medical therapy alone. Data Sources: PubMed, Scopus, and Google Scholar from 1 December 2004 through 14 September 2017; references of eligible studies; relevant scientific session abstracts; and cardiology Web sites. Study Selection: Randomized controlled trials, published in English, that compared PFO closure using a currently available device with medical treatment alone and that reported, at minimum, the rates of stroke or transient ischemic attack (TIA) or of new-onset atrial fibrillation (AF) or atrial flutter (AFL). Data Extraction: 2 investigators independently extracted study data and assessed study quality. Data Synthesis: 4 of 5 trials comparing PFO closure with medical therapy used commercially available devices. These 4 trials, involving 2531 patients, found that PFO closure reduced the risk for the main outcome of stroke or TIA (risk difference [RD], −0.029 [95% CI, −0.050 to −0.007]) and increased the risk for new-onset AF or AFL (RD, 0.033 [CI, 0.012 to 0.054]). The beneficial effect of PFO closure was associated with larger interatrial shunts (P = 0.034). Limitation: Trials were not double-blind, and inclusion criteria were heterogeneous. Conclusion: Compared with medical treatment, PFO closure prevents recurrent stroke and TIA but increases the incidence of AF or AFL in PFO carriers with cryptogenic stroke. Primary Funding Source: Italian Ministry of Education, University and Research (MIUR). (PROSPERO: CRD42017074686)
Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke: A Systematic Review and Meta-analysis Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-09 Rahman Shah, Mannu Nayyar, Ion S. Jovin, Abdul Rashid, Beatrix R. Bondy, Tai-Hwang M. Fan, Michael P. Flaherty, Sunil V. Rao
Background: The optimal strategy for preventing recurrent stroke in patients with cryptogenic stroke and patent foramen ovale (PFO) is unknown. Purpose: To compare transcatheter PFO closure with medical therapy alone for prevention of recurrent stroke in patients with PFO and cryptogenic stroke. Data Sources: PubMed and the Cochrane Library (without language restrictions) from inception to October 2017, reference lists, and abstracts from cardiology meetings. Study Selection: Randomized trials enrolling adults with PFO and cryptogenic stroke that compared stroke outcomes (main outcome) and potential harms in those receiving transcatheter device closure versus medical therapy alone. Data Extraction: Two investigators independently extracted study data and rated risk of bias. Data Synthesis: Of 5 trials, 1 was excluded because it used a device that is no longer available due to high rates of complications and failure. Four high-quality trials enrolling 2892 patients showed that PFO closure decreased the absolute risk for recurrent stroke by 3.2% (risk difference, −0.032 [95% CI, −0.050 to −0.014]) compared with medical therapy. The treatment strategies did not differ in rates of transient ischemic attack or major bleeding. Closure of PFOs was associated with higher rates of new-onset atrial fibrillation (AF) than medical therapy alone in all trials, but this outcome had marked between-trial heterogeneity (I2 = 82.5%), and high event rates in some groups resulted in extreme values for CIs. Limitation: Heterogeneity of device type and antithrombotic therapy across trials, small numbers for some outcomes, and heterogeneous and inconclusive AF results. Conclusion: In patients with PFO and cryptogenic stroke, transcatheter device closure decreases risk for recurrent stroke compared with medical therapy alone. Because recurrent stroke rates are low even with medical therapy alone and PFO closure might affect AF risk, shared decision making is crucial for this treatment. Primary Funding Source: None.
Effect of Physical Activity on Frailty: Secondary Analysis of a Randomized Controlled Trial Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-09 Andrea Trombetti, Mélany Hars, Fang-Chi Hsu, Kieran F. Reid, Timothy S. Church, Thomas M. Gill, Abby C. King, Christine K. Liu, Todd M. Manini, Mary M. McDermott, Anne B. Newman, W. Jack Rejeski, Jack M. Guralnik, Marco Pahor, Roger A. Fielding
Background: Limited evidence suggests that physical activity may prevent frailty and associated negative outcomes in older adults. Definitive data from large long-term randomized trials are lacking. Objective: To determine whether a long-term, structured, moderate-intensity physical activity program is associated with a lower risk for frailty and whether frailty status alters the effect of physical activity on the reduction in major mobility disability (MMD) risk. Design: Multicenter, single-blind, randomized trial. Setting: 8 centers in the United States. Participants: 1635 community-dwelling adults, aged 70 to 89 years, with functional limitations. Intervention: A structured, moderate-intensity physical activity program incorporating aerobic, resistance, and flexibility activities or a health education program consisting of workshops and stretching exercises. Measurements: Frailty, as defined by the SOF (Study of Osteoporotic Fractures) index, at baseline and 6, 12, and 24 months, and MMD, defined as the inability to walk 400 m, for up to 3.5 years. Results: Over 24 months of follow-up, the risk for frailty (n = 1623) was not statistically significantly different in the physical activity versus the health education group (adjusted prevalence difference, −0.021 [95% CI, −0.049 to 0.007]). Among the 3 criteria of the SOF index, the physical activity intervention was associated with improvement in the inability to rise from a chair (adjusted prevalence difference, −0.050 [CI, −0.081 to −0.020]). Baseline frailty status did not modify the effect of physical activity on reducing incident MMD (P for interaction = 0.91). Limitation: Frailty status was neither an entry criterion nor a randomization stratum. Conclusion: A structured, moderate-intensity physical activity program was not associated with a reduced risk for frailty over 2 years among sedentary, community-dwelling older adults. The beneficial effect of physical activity on the incidence of MMD did not differ between frail and nonfrail participants. Primary Funding Source: National Institute on Aging, National Institutes of Health.
Travel Medicine Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-02 Daniel T. Leung, Regina C. LaRocque, Edward T. Ryan
International travel can result in new illness or exacerbate existing conditions, and primary care clinicians have the opportunity to provide both pre- and posttravel health care. Providers should be familiar with destination-specific disease risks, be knowledgeable about travel and routine vaccines, be prepared to prescribe chemoprophylaxis and self-treatment regimens, and be aware of travel medicine resources.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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