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 WeissJFreemanMLowAFuRKerfootAPaynterRet alBenefits and harms of intensive blood pressure treatment in adults aged 60 years or older. A systematic review and meta-analysis,Ann Intern Med201716641929CrossRef 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.
Annals for Educators - 2 January 2018 Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-02 Darren B. Taichman
Clinical Practice Points Effect of Several Negative Rounds of Human Papillomavirus and Cytology Co-testing on Safety Against Cervical Cancer. An Observational Cohort Study The optimal interval for concurrent high-risk human papillomavirus (HPV) and cytology testing (co-testing) to detect cervical cancer and its precursors is a question of great interest. Data from a large regional integrated health system were analyzed to determine whether a history of negative high-risk HPV and cytology co-testing results at 3 or 5 years has an effect on such detection.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what the risk factors for cervical cancer are. What is the role of HPV in the pathogenesis?What are your learners' approaches to screening their patients for cervical cancer? Whom do they screen? How? How often?What do guidelines recommend? Use the information at DynaMed Plus: Cervical Cancer Screening (a benefit of your ACP membership). Do your learners use HPV testing and/or cytology testing? Do they perform co-testing? How might the results of this study help inform future cervical cancer screening guidelines with regard to the necessary frequency of screening? Use the accompanying editorial to help frame your discussion. Preventing Cognitive Impairment and Dementia Physical Activity Interventions in Preventing Cognitive Decline and Alzheimer-Type Dementia. A Systematic Review Pharmacologic Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia. A Systematic Review Over-the-Counter Supplement Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia. A Systematic Review Does Cognitive Training Prevent Cognitive Decline? A Systematic Review These systematic reviews evaluate several types of interventions that have been proposed to help prevent the development or progression of mild cognitive impairment or dementia.Use these studies to:Ask your learners whether they assess their patients for mild cognitive impairment or dementia. How is each diagnosed? What tools are available to help in the evaluation?Have your team list possible interventions to prevent the development or progression of cognitive impairment. Does their list include the approaches studied in these systematic reviews (physical activity, medications, over-the-counter supplements, and cognitive training)? Have their patients expressed concern about preventing cognitive decline? Do your learners recommend any of these approaches to prevention?Assign individuals to briefly summarize the findings of these systematic reviews at your next session so that each is reviewed for the group.After hearing each presentation, ask whether your team believes anything can be done to prevent cognitive decline. Why do they think that finding solutions to this enormous problem is so difficult? Use the accompanying editorial to help frame your discussion. The editorialist suggests recommendations that might prevent cognitive decline later in life. Each recommendation is something we should already be doing but are less than perfect at adhering to. Do your learners think that the possibility of delaying or preventing cognitive decline will be a better incentive to exercise or quit smoking than the reasons we already give our patients? How would your learners explain these recommendations to their patients?In the Clinic In the Clinic: Travel Medicine Primary care physicians are frequent sources of health advice for U.S. international travelers. In addition, returned travelers who have become ill may seek care in primary care settings. Thus, physicians need to be familiar with destination-specific disease risks, travel and routine vaccines, chemoprophylaxis regimens, and self-treatment regimens for infectious and noninfectious illnesses. Are your learners ready?Use this review to:Invite a member of your institution's travel clinic to join your discussion. What services do they provide? What questions do they ask?Ask your learners whether they ask patients about planned travel. What immunizations are required? How can your learners arrange for these immunizations for their patients?Who requires malaria prophylaxis, and what are the options?What should your learners tell their patients about preventing travelers' diarrhea? Should they provide antibiotics in case they are needed? What should travelers pack in a traveler's kit? Review the Box (Travel Health Kit for International Travelers).What advice should your learners give their patients in case they become ill during travel?Answer these and the other questions addressed in this eminently practical review.Download the teaching slides to help run a teaching session. Use the provided multiple-choice questions to introduce new topics along the way, and be sure to log on and enter your answers to earn CME/MOC credit for yourself!Annals Graphic Medicine and Annals Story Slam Annals Graphic Medicine - Back to Work Dr. Farris recalls the trying moments of being “Doctor Mom.”Use this feature to:Before the teaching session, ask your learners who are parents whether they would like to discuss the challenges they have faced with their colleagues. Make sure they are comfortable saying no or setting limits on what they will discuss.Share the comic with your learners.Watch some of the Annals Story Slam videos from July 2017, in which physicians discuss their experiences being “Doctor Mom.” What specific challenges are faced by mothers as they balance being a parent with being a physician? Are the challenges different than for fathers? Do your learners think that your program is sufficiently helpful in supporting physicians who are parents? How could it be improved?MKSAP 17 Question A 26-year-old woman is evaluated during a routine examination. Her last Pap smear was performed 1 year ago and was normal. She has received a complete human papillomavirus (HPV) quadrivalent vaccine series. Medical history is unremarkable. Family history is noncontributory. She takes no medications.On physical examination, temperature is normal, blood pressure is 110/72 mm Hg, and pulse rate is 78/min. The remainder of the physical examination is normal.Which of the following is the most appropriate management of this patient's cervical cancer screening?A. Obtain HPV testing in 2 yearsB. Obtain Pap smear in 2 yearsC. Obtain Pap smear and HPV testing nowD. Obtain Pap smear and HPV testing in 2 yearsCorrect AnswerB. Obtain Pap smear in 2 yearsEducational ObjectiveScreen for cervical cancer in a young woman.CritiqueThis patient should receive a Pap smear in 2 years. According to the U.S. Preventive Services Task Force and the American Congress of Obstetricians and Gynecologists, women aged 21 to 65 years should be screened for cervical cancer every 3 years with cytology (Pap smear). Performing screening more frequently adds little benefit while significantly increasing harms. Harms can include evaluation and treatment of transient lesions as well as false-positive screening results, which may lead to unnecessary colposcopies and emotional distress. Screening for cervical cancer is not recommended in women younger than 21 years, women age 65 years and older who are not at high risk and have had adequate prior Pap smears, and women who have had a hysterectomy with removal of the cervix with no previous history of a precancerous lesion. This patient had a normal Pap smear 1 year ago; therefore, she will be due for her next Pap smear in 2 years.Owing to poor specificity, screening with human papillomavirus (HPV) DNA testing alone is not recommended. HPV testing is not recommended in women younger than 30 years, as HPV is not only highly prevalent but is also more likely to resolve without treatment in this age group. In women aged 30 to 65 years who want to lengthen the screening interval, a combination of cytology and HPV testing can be performed every 5 years. Women should be informed that there is an increased likelihood of receiving a positive screening result with HPV testing and cytology than with cytology alone. A positive HPV test result likely requires additional immediate testing and also involves more frequent surveillance.All females aged 11 to 26 years should be vaccinated against HPV. HPV vaccination status does not alter recommendations for cervical cancer screening.Key PointWomen aged 21 to 65 years should be screened for cervical cancer every 3 years with cytology (Pap smear); in women aged 30 to 65 years who want to lengthen the screening interval, a combination of cytology and human papillomavirus testing can be performed every 5 years.BibliographyMoyer VA; U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jun 19;156(12):880-91, W312.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Correction: Tailoring Treatment of Latent Tuberculosis to the Needs of Patients and Families Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-02
The print version of a recent editorial (1) contained an error. The third sentence should read: “… in 2016 an estimated 10.4 million persons developed the disease and 1.7 million [as opposed to 1.8 million] died of it.”This has been corrected.References GetahunHMatteelliATailoring treatment of latent tuberculosis to the needs of patients and familiesAnn Intern Med20171677423CrossRef PubMed
Correction: In the Clinic—Acute Kidney Injury Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-02
In a recent In the Clinic (1), “serum creatinine clearance” should be “serum creatinine concentration” in 3 places in Figure 1 and the footnote adjacent to the asterisk in Appendix Table 1.This has been corrected.References LeveyASJamesMTAcute kidney injuryAnn Intern Med2017167ITC6680CrossRef PubMed
Use of Immune Checkpoint Inhibitors in the Treatment of Patients With Cancer and Preexisting Autoimmune Disease: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-02 Noha Abdel-Wahab, Mohsin Shah, Maria A. Lopez-Olivo, Maria E. Suarez-Almazor
Background:Cancer immunotherapy with checkpoint inhibitors (CPIs) is associated with frequent immune-related adverse events (irAEs) and is often not recommended for patients with concomitant autoimmune disease.Purpose:To summarize the evidence on adverse events associated with CPIs in patients with cancer and preexisting autoimmune disease.Data Sources:MEDLINE, EMBASE, Web of Science, PubMed ePubs, and the Cochrane Central Register of Controlled Trials through September 2017 with no language restrictions.Study Selection:Original case reports, case series, and observational studies describing patients with cancer and autoimmune disease who were receiving CPIs.Data Extraction:2 reviewers independently extracted data and assessed the quality of reporting.Data Synthesis:123 patients in 49 publications were identified; 92 (75%) had exacerbation of preexisting autoimmune disease, irAEs, or both. No differences in adverse events were observed in patients with active versus inactive disease. Patients receiving immunosuppressive therapy at initiation of CPI therapy seemed to have fewer adverse events than those not receiving treatment. Most flares and irAEs were managed with corticosteroids; 16% required other immunosuppressive therapies. Adverse events improved in more than half of patients without discontinuation of CPI therapy. Three patients died of adverse events.Limitations:The quality and quantity of data were limited. Case reports typically describe unique manifestations and are not generalizable to the population at large. Because there were no prospective observational studies, incidence could not be determined.Conclusion:Flares and irAEs in patients with autoimmune disease who are receiving CPIs can often be managed without discontinuing therapy, although some events may be severe and fatal. Prospective longitudinal studies are needed to establish incidence of adverse events and evaluate risk–benefit ratios and patient preferences in this population.Primary Funding Source:National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Risk-Targeted Lung Cancer Screening: A Cost-Effectiveness Analysis Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-02 Vaibhav Kumar, Joshua T. Cohen, David van Klaveren, Djøra I. Soeteman, John B. Wong, Peter J. Neumann, David M. Kent
Background:Targeting low-dose computed tomography (LDCT) for lung cancer screening to persons at highest risk for lung cancer mortality has been suggested to improve screening efficiency.Objective:To quantify the value of risk-targeted selection for lung cancer screening compared with National Lung Screening Trial (NLST) eligibility criteria.Design:Cost-effectiveness analysis using a multistate prediction model.Data Sources:NLST.Target Population:Current and former smokers eligible for lung cancer screening.Time Horizon:Lifetime.Perspective:Health care sector.Intervention:Risk-targeted versus NLST-based screening.Outcome Measures:Incremental 7-year mortality, life expectancy, quality-adjusted life-years (QALYs), costs, and cost-effectiveness of screening with LDCT versus chest radiography at each decile of lung cancer mortality risk.Results of Base-Case Analysis:Participants at greater risk for lung cancer mortality were older and had more comorbid conditions and higher screening-related costs. The incremental lung cancer mortality benefits during the first 7 years ranged from 1.2 to 9.5 lung cancer deaths prevented per 10 000 person-years for the lowest to highest risk deciles, respectively (extreme decile ratio, 7.9). The gradient of benefits across risk groups, however, was attenuated in terms of life-years (extreme decile ratio, 3.6) and QALYs (extreme decile ratio, 2.4). The incremental cost-effectiveness ratios (ICERs) were similar across risk deciles ($75 000 per QALY in the lowest risk decile to $53 000 per QALY in the highest risk decile). Payers willing to pay $100 000 per QALY would pay for LDCT screening for all decile groups.Results of Sensitivity Analysis:Alternative assumptions did not substantially alter our findings.Limitation:Our model did not account for all correlated differences between lung cancer mortality risk and quality of life.Conclusions:Although risk targeting may improve screening efficiency in terms of early lung cancer mortality per person screened, the gains in efficiency are attenuated and modest in terms of life-years, QALYs, and cost-effectiveness.Primary Funding Source:National Institutes of Health (U01NS086294).
Comparison of Five Major Guidelines for Statin Use in Primary Prevention in a Contemporary General Population Ann. Intern. Med. (IF 17.135) Pub Date : 2018-01-02 Martin Bødtker Mortensen, Børge Grønne Nordestgaard
Background:Five major organizations recently published guidelines for using statins to prevent atherosclerotic cardiovascular disease (ASCVD): in 2013, the American College of Cardiology/American Heart Association (ACC/AHA); in 2014, the United Kingdom's National Institute for Health and Care Excellence (NICE); and in 2016, the Canadian Cardiovascular Society (CCS), the U.S. Preventive Services Task Force (USPSTF), and the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS).Objective:To compare the utility of these guidelines for primary prevention of ASCVD.Design:Observational study of actual ASCVD events during 10 years, followed by a modeling study to estimate the effectiveness of different guidelines.Setting:The Copenhagen General Population Study.Participants:45 750 Danish persons aged 40 to 75 years who did not use statins and did not have ASCVD at baseline.Measurements:The number of participants eligible to use statins according to each guideline and the estimated number of ASCVD events that statins could have prevented.Results:The percentage of participants eligible for statins was 44% by the CCS guideline, 42% by ACC/AHA, 40% by NICE, 31% by USPSTF, and 15% by ESC/EAS. The estimated percentage of ASCVD events that could have been prevented by using statins for 10 years was 34% for CCS, 34% for ACC/AHA, 32% for NICE, 27% for USPSTF, and 13% for ESC/EAS.Limitation:This study was limited to primary prevention in white Europeans.Conclusion:Guidelines recommending that more persons use statins for primary prevention of ASCVD should prevent more events than guidelines recommending use by fewer persons.Primary Funding Source:Copenhagen University Hospital.
Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-26 Katherine T. Mills, Katherine M. Obst, Wei Shen, Sandra Molina, Hui-Jie Zhang, Hua He, Lisa A. Cooper, Jiang He
Background: The prevalence of hypertension is high and is increasing worldwide, whereas the proportion of controlled hypertension is low. Purpose: To assess the comparative effectiveness of 8 implementation strategies for blood pressure (BP) control in adults with hypertension. Data Sources: Systematic searches of MEDLINE and Embase from inception to September 2017 with no language restrictions, supplemented with manual reference searches. Study Selection: Randomized controlled trials lasting at least 6 months comparing the effect of implementation strategies versus usual care on BP reduction in adults with hypertension. Data Extraction: Two investigators independently extracted data and assessed study quality. Data Synthesis: A total of 121 comparisons from 100 articles with 55 920 hypertensive patients were included. Multilevel, multicomponent strategies were most effective for systolic BP reduction, including team-based care with medication titration by a nonphysician (−7.1 mm Hg [95% CI, −8.9 to −5.2 mm Hg]), team-based care with medication titration by a physician (−6.2 mm Hg [CI, −8.1 to −4.2 mm Hg]), and multilevel strategies without team-based care (−5.0 mm Hg [CI, −8.0 to −2.0 mm Hg]). Patient-level strategies resulted in systolic BP changes of −3.9 mm Hg (CI, −5.4 to −2.3 mm Hg) for health coaching and −2.7 mm Hg (CI, −3.6 to −1.7 mm Hg) for home BP monitoring. Similar trends were seen for diastolic BP reduction. Limitation: Sparse data from low- and middle-income countries; few trials of some implementation strategies, such as provider training; and possible publication bias. Conclusion: Multilevel, multicomponent strategies, followed by patient-level strategies, are most effective for BP control in patients with hypertension and should be used to improve hypertension control. Primary Funding Source: National Institutes of Health.
Low Prevalence of Hepatitis B Vaccination Among Patients Receiving Medical Care for HIV Infection in the United States, 2009 to 2012 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-26 John Weiser, Alejandro Perez, Heather Bradley, Hope King, R. Luke Shouse
Background: Persons with HIV infection are at increased risk for hepatitis B virus infection. In 2016, the World Health Organization resolved to eliminate hepatitis B as a public health threat by 2030. Objective: To estimate the prevalence of hepatitis B vaccination among U.S. patients receiving medical care for HIV infection (“HIV patients”). Design: Nationally representative cross-sectional survey. Setting: United States. Participants: 18 089 adults receiving HIV medical care who participated in the Medical Monitoring Project during 2009 to 2012. Measurements: Primary outcomes were prevalence of 1) no documentation of hepatitis B vaccination or laboratory evidence of immunity or infection (candidates to initiate vaccination), and 2) initiation of vaccination among candidates, defined as documentation of at least 1 vaccine dose in a 1-year surveillance period during which patients received ongoing HIV medical care. Results: At the beginning of the surveillance period, 44.2% (95% CI, 42.2% to 46.2%) of U.S. HIV patients were candidates to initiate vaccination. By the end of the surveillance period, 9.6% (CI, 8.4% to 10.8%) of candidates were vaccinated, 7.5% (CI, 6.4% to 8.6%) had no documented vaccination but had documented infection or immunity, and 82.9% (CI, 81.1% to 84.7%) remained candidates. Among patients at facilities funded by the Ryan White HIV/AIDS Program (RWHAP), 12.5% (CI, 11.1% to 13.9%) were vaccinated during the surveillance period versus 3.7% (CI, 2.6% to 4.7%) at facilities not funded by RWHAP. At the end of surveillance, 36.7% (CI, 34.4% to 38.9%) of HIV patients were candidates to initiate vaccination. Limitation: The study was not designed to describe vaccine series completion or actual prevalence of immunity. Conclusion: More than one third of U.S. HIV patients had missed opportunities to initiate hepatitis B vaccination. Meeting goals for hepatitis B elimination will require increased vaccination of HIV patients in all practice settings, particularly at facilities not funded by RWHAP. Primary Funding Source: Centers for Disease Control and Prevention.
Annals Story Slam - Unlisted Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Steven McKee
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - There's No Place Like Home Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Lisa Bellini
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - Just One More Question Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Joel A. Fein
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - I Don't Think It's a Good Fit Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Kate Yun
Annals Story Slam - Getting Home Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Janelle Mirabeau
Annals Story Slam - A Son of Health Disparity Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Kevin A. Jenkins
Annals Story Slam - A Long Stay Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Stephanie Smith
Annals for Hospitalists - 19 December 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 David H. Wesorick, Vineet Chopra
Inpatient Notes Trends in Rates of Catheter-Associated Bloodstream Infection—Zeroing In on Zero or Just Fake News? —Naomi P. O’Grady, MD In recent years, rates of catheter-associated bloodstream infections have dropped dramatically. In this issue's Inpatient Notes, the author discusses the interventions that may have brought about this improvement and suggests that the numbers may not be telling the whole story. Highlights of Recent Articles From Annals of Internal Medicine Outcomes of Dabigatran and Warfarin for Atrial Fibrillation in Contemporary Practice: A Retrospective Cohort Study Ann Intern Med. 2017;167:845-854. Published 14 November 2017. doi:10.7326/M16-1157 This large retrospective study analyzed data from the U.S. Food and Drug Administration Sentinel Initiative, a national surveillance system, to compare rates of ischemic stroke, intracranial hemorrhage, extracranial bleeding, and myocardial infarction (MI) in patients taking warfarin or dabigatran. Investigators compared 25 289 patients starting warfarin with 25 289 propensity score-matched patients starting dabigatran for atrial fibrillation. The analysis revealed that patients treated with dabigatran had similar rates of ischemic stroke and extracranial bleeding as patients taking warfarin; however, they experienced less frequent intracranial bleeding (0.39 vs. 0.77 events per 100 person-years; hazard ratio, 0.51 [CI, 0.33 to 0.79]) but more frequent MI (0.77 vs. 0.43 events per 100 person-years; hazard ratio, 1.88 [CI, 1.22 to 2.90]). Key points for hospitalists include: In this real-world setting, dabigatran was as equally effective in preventing stroke as warfarin and was associated with fewer intracranial bleeding episodes. Dabigatran was associated with higher rates of MI than warfarin. However, the authors questioned the validity of this finding, given a lack of statistical significance in sensitivity analyses. Subgroup analysis did show higher rates of MI in patients treated with dabigatran who were men and were older than 75 years and showed higher rates of gastrointestinal bleeding in patients treated with dabigatran who also had renal dysfunction and were older than 75 years. Measuring Patient Safety in Real Time: An Essential Method for Effectively Improving the Safety of Care Ann Intern Med. 2017;167:882-883. Published 21 November 2017. doi:10.7326/M17-2202 This Ideas and Opinions piece describes the electronic health record as a powerful tool in detecting harm from medical error that very few hospitals are using to its full potential. Most hospitals still rely on voluntary reporting to detect errors, but this is known to be an insensitive method for detecting harm. The authors suggest that emerging techniques should allow all hospitals to use their electronic health records to facilitate detection of harm from medical error. Key points for hospitalists include: Hospitals can use the electronic health record to search for triggers associated with harmful errors, allowing targeted record reviews. This type of triggered review can detect more than 90% of harm in hospitalized patients. Hospitals can automate reporting of certain lab values to identify important conditions (e.g., reports of blood cultures results may be used to identify catheter-associated bloodstream infection). Introducing a Patient Portal and Electronic Tablets to Inpatient Care Ann Intern Med. 2017;167:816-817. Published 24 October 2017. doi:10.7326/M17-1766 This Ideas and Opinions piece introduces the notion of creating an electronic patient portal for hospitalized patients. Electronic patient portals are frequently used in the outpatient arena and seem to engage patients in their own care. However, they have not been well-studied in the inpatient setting. These portals can allow hospitalized patients to see their own health records, including test results and medication administration records, a roster of the care team, and a daily care plan. They can also allow patients to save notes or questions and to communicate more directly and asynchronously with the care team. A small pilot study conducted by the authors showed that patients using an electronic portal had higher satisfaction scores than contemporaneous controls that did not have access to the portal. Key points for hospitalists include: Although evidence is limited, electronic patient portals may be useful in increasing satisfaction and engagement of hospitalized patients. The Latest Highlights From ACP Journal Club How should antirheumatic drugs be managed in patients having joint replacement surgery? Guideline: Recommendations for THA or TKA perioperative antirheumatic drugs in patients with rheumatic diseases Ann Intern Med. 2017;167:JC50. doi:10.7326/ACPJC-2017-167-10-050 This guideline is based on a systematic review of the literature examining studies that addressed perioperative management of antirheumatic medications. Although most of the included evidence was of low quality, recommendations from a panel of experts were almost unanimous in endorsing the following clinical practices: a) to continue perioperative home doses of glucocorticoids (as opposed to stress doses) during surgery; b) to continue nonbiologic disease–modifying antirheumatic drugs in the perioperative setting; and c), to avoid use or initiation of biologic agents in the perioperative period. How reliable is computed tomography pulmonary angiography (CTPA) for ruling out suspected pulmonary embolism? In suspected PE, 2% of patients with a Wells score >4 and negative CT pulmonary angiography had VTE at 3 months Ann Intern Med. 2017;167:JC59. doi:10.7326/ACPJC-2017-167-10-059 In this patient level meta-analysis, data from 4 prospective diagnosis and treatment trials (n = 6148) were analyzed and revealed that for patients with a Wells score >4 and negative CTPA, 2% had venous thromboembolism and 0.48% had fatal pulmonary embolism at 3 months. The findings suggest that although powerful, CTPA is an imperfect test. Thus, it may be useful to maintain a low threshold to reinvestigate patients with negative CTPA and a high clinical probability of disease if symptoms persist or worsen. Sign up here to have Annals for Hospitalists delivered to your inbox each month.
Annals for Educators - 19 December 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Darren B. Taichman
Clinical Practice Points Management of Suspected Opioid Overdose With Naloxone in Out-of-Hospital Settings. A Systematic Review This systematic review examines whether the route of administration and dosing of naloxone affect clinical outcomes in adults with suspected opioid overdose. Use this study to: Ask your learners what the physical examination of a patient who has had an opioid overdose might reveal. How should opioid overdose be managed? What needs to be done first? How is response evaluated, and for how long should patients be monitored? Which patients require intubation? The authors of the review and the editorialists note substantial deficiencies in evidence for the optimal dose and route of administration of naloxone and the need for transportation to the hospital after out-of-hospital administration. What might be the barriers to performing randomized trials to address these issues? How should patients who have had an opioid overdose be assisted after emergency care? What is the role of pharmacologic agents, such as methadone or buprenorphine? How are they initiated, and what are the regulations related to their use? How are patients followed? Invite a specialist in the use of these agents to join your discussion. Pharmacologic Treatment of Seasonal Allergic Rhinitis: Synopsis of Guidance From the 2017 Joint Task Force on Practice Parameters This synopsis of guidance from the Joint Task Force on Practice Parameters provides 3 recommendations for the initial pharmacologic treatment of seasonal allergic rhinitis. Use this paper to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners how they approach the evaluation of a patient presenting with nasal congestion and/or rhinitis. What should they ask? What should they look for on examination? What interventions do your learners consider for patients with allergic rhinitis? Is allergen avoidance sufficient? Do your learners ever prescribe leukotriene inhibitors? When? What does this guideline conclude about their use for allergic rhinitis? What if the patient has a concomitant diagnosis of mild persistent asthma? Are your learners able to recognize nasal polyps? If present, how do they affect management? Should referral for removal be considered? Improving Diagnostic Skills Getting It Right: Cases to Improve Diagnosis Diagnosis is one of the most important and challenging tasks that a physician performs, particularly in internal medicine. The rate of diagnostic error is estimated to be 10% to 15% for internists. Unfortunately, these errors result in substantial morbidity and mortality for patients. Diagnostic errors are the leading type of paid medical malpractice claim and are nearly twice as likely to result in death as any other category of error. This unique case-based educational program provides tools to help improve your learners' (and your own!) diagnostic skills. Use this unique feature to: Start a teaching session by reading one of the brief case presentations with your learners. You can do one in a few minutes at the beginning of each of several sessions. Discuss the possible answers with your team and then review the answer critique together. Did you get it right? Ask what “illness scripts,” “diagnostic momentum,” and “diagnostic timeouts” are. Claim CME and MOC credit for yourself. Humanism and Professionalism Ad Libitum: A Time to Talk Dr. Gianakos and others have noticed worrisome changes in his colleague's behavior. At first, they may not have garnered attention, but he puts aside his overwhelming workload to pay attention. Use this piece to: Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether Jane's behaviors would alarm them if a colleague displayed them or whether they would be seen as normal. Can you tell the difference? What must we do if we suspect a colleague is struggling? What should we do if we're struggling ourselves? How do we position ourselves physically to show others that we are really listening? Do we put away our cellphones? Do we come out from behind our computers? How does that help those in need of our ear? How does it help us? Do your learners know what resources are available to them if they are struggling? Do your learners know what to do when a colleague reaches out for help? What if your learners think the colleague needs assistance from others? What if the colleague refuses? MKSAP 17 Question A 42-year-old man is evaluated for a 3-month history of cough. He describes the cough as nonproductive and associated with sinus congestion. He also notes increased mucus production with frequent throat clearing. He has no shortness of breath, wheezing, hemoptysis, or chest pain. He does not notice any change in cough with exercise. He reports that he has had similar extended periods of cough in the past, usually in either the fall or spring. He has tried over-the-counter dextromethorphan and decongestants, alone and in combination, without noticeable improvement. Medical history is otherwise unremarkable. He is a never-smoker and takes no medications. On physical examination, the patient is afebrile, blood pressure is 124/84 mm Hg, pulse rate is 68/min, and respiration rate is 15/min. Nasal turbinates are boggy. The lungs are clear to auscultation. The remainder of the examination is normal. Which of the following is the most appropriate treatment? A. Antibiotic therapy B. Antihistamine-decongestant C. Inhaled bronchodilator D. Intranasal glucocorticoid Correct Answer D. Intranasal glucocorticoid Educational Objective Treat upper airway cough syndrome due to allergic rhinitis. Critique The most appropriate treatment for this patient is an intranasal glucocorticoid. This patient has chronic cough (cough of more than 8 weeks' duration) due to upper airway cough syndrome (UACS) associated with allergic rhinitis. UACS is associated with conditions that cause excessive mucus production in the upper airways and postnasal drip, triggering cough. Allergic rhinitis is a frequent cause of UACS and is likely in this patient with evidence of seasonal allergies (clear nasal drainage, postnasal drip) and symptoms that are worse in high allergy seasons (fall and spring). Patients with UACS due to allergic rhinitis respond well to intranasal glucocorticoids, and these agents are considered first-line therapy. Antibiotics are not indicated in this patient who has no clinical evidence of acute or chronic bacterial sinusitis. First-generation antihistamine and decongestant therapy is recommended for patients with UACS due to nonallergic rhinitis. Since this patient's presentation is typical of seasonal allergies, intranasal glucocorticoids are a better option. Additionally, the systemic side effects associated with oral medications do not occur with intranasal administration. Although cough can be a manifestation of asthma, this patient had no reports of wheezing, even with exercise, and physical examination did not reveal the presence of wheeze or airflow limitation. Therefore, inhaled bronchodilators are not indicated. Key Point Intranasal glucocorticoids are first-line therapy for patients with upper airway cough syndrome due to allergic rhinitis; antibiotics should not be used without clear evidence of bacterial infection. Bibliography Wallace DV, Dykewicz MS, Bernstein DI, et al; Joint Task Force on Practice; American Academy of Allergy; Asthma Immunology; American College of Allergy; Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008 Aug;122(2 Suppl):S1-84. Erratum in: J Allergy Clin Immunol. 2008 Dec;122(6):1237. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Correction: Functional Status and Quality of Life After Transcatheter Aortic Valve Replacement Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19
There were errors in a review (1) regarding the minimal clinically important difference for the Kansas City Cardiomyopathy Questionnaire score. In the Data Extraction and Quality Assessment section and in Appendix Table 1, the score was given as ≥20 points but should have been ≥5 points. In Appendix Table 5, in the transfemoral discussion of Lefèvre and colleagues' study, the baseline mean value should be 50 points and the main finding should state that the mean increase in the score was clinically and statistically significant. This has been corrected in the online version. References Kim CA Rasania SP Afilalo J Popma JJ Lipsitz LA Kim DH Functional status and quality of life after transcatheter aortic valve replacement: a systematic review Ann Intern Med 2014 160 243 54 CrossRef PubMed
Physical Activity Interventions in Preventing Cognitive Decline and Alzheimer-Type Dementia: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Michelle Brasure, Priyanka Desai, Heather Davila, Victoria A. Nelson, Collin Calvert, Eric Jutkowitz, Mary Butler, Howard A. Fink, Edward Ratner, Laura S. Hemmy, J. Riley McCarten, Terry R. Barclay, Robert L. Kane
Background: The prevalence of cognitive impairment and dementia is expected to increase dramatically as the population ages, creating burdens on families and health care systems. Purpose: To assess the effectiveness of physical activity interventions in slowing cognitive decline and delaying the onset of cognitive impairment and dementia in adults without diagnosed cognitive impairments. Data Sources: Several electronic databases from January 2009 to July 2017 and bibliographies of systematic reviews. Study Selection: Trials published in English that lasted 6 months or longer, enrolled adults without clinically diagnosed cognitive impairments, and compared cognitive and dementia outcomes between physical activity interventions and inactive controls. Data Extraction: Extraction by 1 reviewer and confirmed by a second; dual-reviewer assessment of risk of bias; consensus determination of strength of evidence. Data Synthesis: Of 32 eligible trials, 16 with low to moderate risk of bias compared a physical activity intervention with an inactive control. Most trials had 6-month follow-up; a few had 1- or 2-year follow-up. Evidence was insufficient to draw conclusions about the effectiveness of aerobic training, resistance training, or tai chi for improving cognition. Low-strength evidence showed that multicomponent physical activity interventions had no effect on cognitive function. Low-strength evidence showed that a multidomain intervention comprising physical activity, diet, and cognitive training improved several cognitive outcomes. Evidence regarding effects on dementia prevention was insufficient for all physical activity interventions. Limitation: Heterogeneous interventions and cognitive test measures, small and underpowered studies, and inability to assess the clinical significance of cognitive test outcomes. Conclusion: Evidence that short-term, single-component physical activity interventions promote cognitive function and prevent cognitive decline or dementia in older adults is largely insufficient. A multidomain intervention showed a delay in cognitive decline (low-strength evidence). Primary Funding Source: Agency for Healthcare Research and Quality.
Pharmacologic Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Howard A. Fink, Eric Jutkowitz, J. Riley McCarten, Laura S. Hemmy, Mary Butler, Heather Davila, Edward Ratner, Collin Calvert, Terry R. Barclay, Michelle Brasure, Victoria A. Nelson, Robert L. Kane
Background: Optimal treatment to prevent or delay cognitive decline, mild cognitive impairment (MCI), or dementia is uncertain. Purpose: To summarize current evidence on the efficacy and harms of pharmacologic interventions to prevent or delay cognitive decline, MCI, or dementia in adults with normal cognition or MCI. Data Sources: Several electronic databases from January 2009 to July 2017, bibliographies, and expert recommendations. Study Selection: English-language trials of at least 6 months' duration enrolling adults without dementia and comparing pharmacologic interventions with placebo, usual care, or active control on cognitive outcomes. Data Extraction: Two reviewers independently rated risk of bias and strength of evidence; 1 extracted data, and a second checked accuracy. Data Synthesis: Fifty-one unique trials were rated as having low to moderate risk of bias (including 3 that studied dementia medications, 16 antihypertensives, 4 diabetes medications, 2 nonsteroidal anti-inflammatory drugs [NSAIDs] or aspirin, 17 hormones, and 7 lipid-lowering agents). In persons with normal cognition, estrogen and estrogen–progestin increased risk for dementia or a combined outcome of MCI or dementia (1 trial, low strength of evidence); high-dose raloxifene decreased risk for MCI but not for dementia (1 trial, low strength of evidence); and antihypertensives (4 trials), NSAIDs (1 trial), and statins (1 trial) did not alter dementia risk (low to insufficient strength of evidence). In persons with MCI, cholinesterase inhibitors did not reduce dementia risk (1 trial, low strength of evidence). In persons with normal cognition and those with MCI, these pharmacologic treatments neither improved nor slowed decline in cognitive test performance (low to insufficient strength of evidence). Adverse events were inconsistently reported but were increased for estrogen (stroke), estrogen–progestin (stroke, coronary heart disease, invasive breast cancer, and pulmonary embolism), and raloxifene (venous thromboembolism). Limitation: High attrition, short follow-up, inconsistent cognitive outcomes, and possible selective reporting and publication. Conclusion: Evidence does not support use of the studied pharmacologic treatments for cognitive protection in persons with normal cognition or MCI. Primary Funding Source: Agency for Healthcare Research and Quality.
Over-the-Counter Supplement Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Mary Butler, Victoria A. Nelson, Heather Davila, Edward Ratner, Howard A. Fink, Laura S. Hemmy, J. Riley McCarten, Terry R. Barclay, Michelle Brasure, Robert L. Kane
Background: Optimal interventions to prevent or delay cognitive decline, mild cognitive impairment (MCI), or dementia are uncertain. Purpose: To summarize the evidence on efficacy and harms of over-the-counter (OTC) supplements to prevent or delay cognitive decline, MCI, or clinical Alzheimer-type dementia in adults with normal cognition or MCI but no dementia diagnosis. Data Sources: Multiple electronic databases from 2009 to July 2017 and bibliographies of systematic reviews. Study Selection: English-language trials of at least 6 months' duration that enrolled adults without dementia and compared cognitive outcomes with an OTC supplement versus placebo or active controls. Data Extraction: Extraction performed by a single reviewer and confirmed by a second reviewer; dual-reviewer assessment of risk of bias; consensus determination of strength of evidence. Data Synthesis: Thirty-eight trials with low to medium risk of bias compared ω-3 fatty acids, soy, ginkgo biloba, B vitamins, vitamin D plus calcium, vitamin C or β-carotene, multi-ingredient supplements, or other OTC interventions with placebo or other supplements. Few studies examined effects on clinical Alzheimer-type dementia or MCI, and those that did suggested no benefit. Daily folic acid plus vitamin B12 was associated with improvements in performance on some objectively measured memory tests that were statistically significant but of questionable clinical significance. Moderate-strength evidence showed that vitamin E had no benefit on cognition. Evidence about effects of ω-3 fatty acids, soy, ginkgo biloba, folic acid alone or with other B vitamins, β-carotene, vitamin C, vitamin D plus calcium, and multivitamins or multi-ingredient supplements was either insufficient or low-strength, suggesting that these supplements did not reduce risk for cognitive decline. Adverse events were rarely reported. Limitation: Studies had high attrition and short follow-up and used a highly variable set of cognitive outcome measures. Conclusion: Evidence is insufficient to recommend any OTC supplement for cognitive protection in adults with normal cognition or MCI. Primary Funding Source: Agency for Healthcare Research and Quality.
Does Cognitive Training Prevent Cognitive Decline?: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-19 Mary Butler, Ellen McCreedy, Victoria A. Nelson, Priyanka Desai, Edward Ratner, Howard A. Fink, Laura S. Hemmy, J. Riley McCarten, Terry R. Barclay, Michelle Brasure, Heather Davila, Robert L. Kane
Background: Structured activities to stimulate brain function—that is, cognitive training exercises—are promoted to slow or prevent cognitive decline, including dementia, but their effectiveness is highly debated. Purpose: To summarize evidence on the effects of cognitive training on cognitive performance and incident dementia outcomes for adults with normal cognition or mild cognitive impairment (MCI). Data Sources: Ovid MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and PsycINFO through July 2017, supplemented by hand-searches. Study Selection: Trials (published in English) lasting at least 6 months that compared cognitive training with usual care, waitlist, information, or attention controls in adults without dementia. Data Extraction: Single-reviewer extraction of study characteristics confirmed by a second reviewer; dual-reviewer risk-of-bias assessment; consensus determination of strength of evidence. Only studies with low or medium risk of bias were analyzed. Data Synthesis: Of 11 trials with low or medium risk of bias, 6 enrolled healthy adults with normal cognition and 5 enrolled adults with MCI. Trainings for healthy older adults were mostly computer based; those for adults with MCI were mostly held in group sessions. The MCI trials used attention controls more often than trials with healthy populations. For healthy older adults, training improved cognitive performance in the domain trained but not in other domains (moderate-strength evidence). Results for populations with MCI suggested no effect of training on performance (low-strength and insufficient evidence). Evidence for prevention of cognitive decline or dementia was insufficient. Adverse events were not reported. Limitation: Heterogeneous interventions and outcome measures; outcomes that mostly assessed test performance rather than global function or dementia diagnosis; potential publication bias. Conclusion: In older adults with normal cognition, training improves cognitive performance in the domain trained. Evidence regarding prevention or delay of cognitive decline or dementia is insufficient. Primary Funding Source: Agency for Healthcare Research and Quality.
Transport to the Emergency Department for Assisted Living Residents Who Fall Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-12
What is the problem and what is known about it so far? Many people who live in assisted living facilities have a high risk for falling. In addition, many facilities require that anyone who falls be evaluated right away to detect any medical condition that caused the fall or any injury from the fall. Most of these evaluations occur in a hospital emergency department, and they often do not find important problems. As a result, many residents are transported from the facility to the emergency department and back again without benefiting from the experience. Why did the researchers do this particular study? To reduce the number of unnecessary trips to the emergency department. Who was studied? Residents who volunteered and who lived in 1 of several assisted living facilities where 1 group of doctors provided medical care. How was the study done? When emergency medical services were called to an assisted living facility for a resident who fell, paramedics evaluated the person using a written guide that they and the doctors had developed together. The guide indicated when the patient should be transported, when transport was unnecessary, and when the paramedic should call the doctor to discuss the situation. What did the researchers find? The guide recommended no transport for more than half of the people who fell, and nearly all of the people who were treated in the assisted living facility without transport to the emergency department received the care they needed right away. What were the limitations of the study? Few localities in the United States have the combination of emergency medical system and doctor-coverage system that is needed to duplicate this effort. What are the implications of the study? Many people who live in assisted living facilities and fall do not need to be transported to the emergency department.
Cost-Effectiveness of Individualized Management of Diabetes Among U.S. Adults Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-12
What is the problem and what is known about it so far? Hemoglobin is a protein inside red blood cells that helps carry oxygen from the lungs to the rest of the body. Glucose (sugar) in the blood slowly attaches to hemoglobin to form hemoglobin A1c (HbA1c). The more glucose in the blood, the more HbA1c is formed. As a result, the percentage of hemoglobin that is HbA1c reflects the average value for blood sugar during the previous 2 to 3 months. The American Diabetes Association encourages people to use the percentage of HbA1c to keep track of how well their diabetes is being controlled, and until recently doctors would tell people to aim for a target of 7%. But, when everyone has the same target, some people have blood sugar values that are too high and others have values that are too low. As a result, many doctors now increase or decrease the target according to the person's age, medical history, and remaining years of life and how likely they are to have very low blood sugar, which is especially dangerous. Why did the researchers do this particular study? No one knows how much it costs to use different HbA1c targets for different people instead of using the same target for everyone. Who was studied? People with type 2 diabetes who represented all such people in the United States. How was the study done? The researchers created a computer model that combined existing information about the frequency of problems with existing information about how much it costs to treat those problems. The researchers then used the model to predict what problems people might have in the future, how long they would live, and how much it would cost to provide their care. What did the researchers find? Using different targets for different people led to fewer medications, less expensive care, and a slightly shorter length of life but a slightly higher quality of life. What were the limitations of the study? Younger people who don't mind taking a lot of medications might be better off with an HbA1c target of 7%. What are the implications of the study? If individualized HbA1c targets are used more often, people will take fewer medications and will have less expensive care and better quality of life.
Annals for Educators - 5 December 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-12-05 Darren B. Taichman
Clinical Practice Points 46-Year Trends in Systemic Lupus Erythematosus Mortality in the United States, 1968 to 2013. A Nationwide Population-Based Study Diagnostic and treatment advances in systemic lupus erythematosus (SLE) have resulted in improved 5- and 10-year survival rates. This study describes trends in SLE mortality rates in the United States over a 46-year period. Use this study to: Start and end a teaching session with multiple-choice questions. We've provided 2 below! Ask your learners to list the ways SLE might present. How is the diagnosis established? Use the information in DynaMed Plus: Systemic lupus erythematosus, a benefit of your ACP membership. What are the potential complications of SLE? Which ones are life-threatening? Teach at the bedside! Identify a patient on the medical service with SLE, and ask whether she or he would be willing (and even would appreciate) talking to your team about how SLE has affected her or his life. What has been the worst part? What has not been as bad as expected? Are your learners surprised by which manifestations of this disease are most troublesome in the patient's daily life? How is SLE treated? Look at the Figure in this paper with your learners. How do they interpret these findings? What do they tell us about our ability to manage the complications of SLE? Are your learners surprised by the sex, racial, and geographic discrepancies in mortality rates seen in Table 3? Why or why not? Functional Impairment and Decline in Middle Age. A Cohort Study Functional impairments, or limitations in performing activities of daily living (ADLs), are common among middle-aged adults. This article presents data on the incidence and clinical course of functional impairments among community-dwelling, middle-aged adults in the United States. Use this study to: Ask your learners to list ADLs and instrumental ADLs (IADLs). They are listed in the “Measures” subsection of the paper's Methods section. Ask your learners how often they think middle-aged adults develop ADL impairments. Look at Figure 2. Are your learners surprised by these data? Explore the interactive graphic that accompanies this paper. This allows your learners to visualize what happens to a group of people who have anywhere from 0 to 5 impairments. How many recover and become independent again? How many become and remain dependent? Do your learners ask their patients about ADLs and IADLs? Should they? Why do they matter? Have your learners ask each of their patients about ADLs and IADLs before your next meeting. What did they learn? Were they surprised? Why don't we focus on these more routinely? How can we help our patients with ADLs? Invite a rehabilitation physician to join your discussion. Invite an occupational therapist to talk to your team about what they do with patients and which types of impairments are more or less amenable to interventions. Beyond the Guidelines Should This Patient Receive Aspirin? Grand Rounds Discussion From Beth Israel Deaconess Medical Center The U.S. Preventive Services Task Force has concluded that for adults aged 50 to 59 years with a 10-year risk for cardiovascular disease (CVD) of 10% or greater, the benefit of aspirin for both CVD and colorectal cancer prevention moderately outweighs the risk for harm. Here, 2 experts discuss whether to recommend aspirin for a 57-year-old man who has a CVD risk greater than 10% but has concerns about gastrointestinal side effects. Use this feature to: Read the first 4 paragraphs of this paper with your learners for a summary of Mr. C's clinical issue. Then, watch the brief video interview with Mr. C. Ask your learners each of the questions posed to the Beyond the Guidelines discussants: What are the potential benefits of daily low-dose aspirin, and how long do you need to take aspirin to achieve those benefits? What are the potential harms? How do you balance benefits and harms to individualize a risk-based decision for Mr. C in particular and for patients in general? Now, review the answers of the discussants by either reviewing the paper (use the provided slides) or watching the video of the Grand Rounds presentations. Have your learners altered their opinions? Answer the multiple-choice questions, and log on to enter your answers and earn CME/MOC credit for yourself! In the Clinic In the Clinic: Dyslipidemia Dyslipidemia is an important risk factor for coronary artery disease and stroke. Long-term, prospective epidemiologic studies have consistently shown that persons with healthier lifestyles and fewer risk factors for coronary heart disease, particularly those with favorable lipid profiles, have reduced incidence of coronary heart disease. Prevention and sensible management of dyslipidemia can markedly alter cardiovascular morbidity and mortality. Are your learners ready? Use this paper to: Ask your learners whether they screen their patients for dyslipidemia. Which ones? How should screening be performed? Should a fasting lipid panel be used? Should triglycerides be measured? How should the results be interpreted? Ask your learners which drugs can cause dyslipidemia. What behavioral modifications should be recommended? How do your learners choose therapy? Use the Table to help review options with your learners. What are the goals of treatment, and how should patients be monitored? Is repeated testing necessary? How will your learners counsel patients who are concerned about medication adverse effects? What will they say to a patient who wants to use alternative or complementary therapies? Download the teaching slide set. Use the provided multiple-choice questions to help introduce topics during a teaching session. And, log on to enter your answers and earn CME/MOC credit for yourself! Humanism and Professionalism Annals Graphic Medicine - Dear Doctor II KC expresses outrage at the insensitive behavior of the emergency room physician. How could things have gone so wrong? Use this feature to: Look at the cartoon (yes, a cartoon in a serious medical journal) with your learners. Ask whether they believe the emergency room physician is likely to be as callous as he seemed to his patient's family members. Does it matter whether he meant to be rude? Is there another side to the story? The author makes clear that other members of the emergency department team were wonderful. Do your learners think that their behavior has ever inadvertently offended patients or their families? What can we do to prevent this? On Being a Patient Terminal Denial In the first essay, Dr. Lederle describes his thoughts on “coming to terms” with his terminal diagnosis. In the second essay, Dr. Saxe reflects on how her own malignancies and her mother's dementia shattered her “protective wall of denial.” Use these essays to: Listen to an audio recording of each, read by Drs. Michael LaCombe and Virginia Hood. Ask your learners whether hearing about a physician's devastating diagnosis affects them differently from hearing such news about a patient or a family member. Why? Do we learn to put up walls between ourselves and our patients? In what ways are they detrimental? Are they useful in some way? Are there solutions to these opposing effects? Do we all have to endure an illness ourselves or with a family member to shatter the wall? MKSAP 17 Question 1 A 30-year-old woman is evaluated during a follow-up visit for systemic lupus erythematosus. She was diagnosed 3 months ago after presenting with pericarditis and arthritis. She was initially treated with prednisone, 40 mg/d, with improvement of her presenting symptoms. The prednisone has been tapered over 3 months to her current dose of 10 mg/d with no recurrence. She also takes vitamin D and a calcium supplement. On physical examination, vital signs are normal. BMI is 25. Cardiac examination is normal. There is no evidence of arthritis. The remainder of the examination is normal. Which of the following is the most appropriate next step in treating this patient? A. Add azathioprine B. Add hydroxychloroquine C. Add mycophenolate mofetil D. Add a scheduled NSAID Correct Answer B. Add hydroxychloroquine Educational Objective Treat mild systemic lupus erythematosus. Critique Hydroxychloroquine is an appropriate agent to address milder systemic manifestations of systemic lupus erythematosus (SLE) such as arthritis and pericarditis, and it can act as a glucocorticoid-sparing agent. All patients with SLE who can tolerate it should be taking hydroxychloroquine. Antimalarial therapy such as hydroxychloroquine in SLE has documented benefit for reducing disease activity, improving survival, and reducing the risk of SLE-related thrombosis and myocardial infarction. Azathioprine is generally reserved for more severe manifestations of SLE not responsive to low-dose prednisone and hydroxychloroquine but can be associated with serious toxicity. Azathioprine has generally been supplanted by the use of mycophenolate mofetil in SLE. Mycophenolate mofetil may be appropriate for this patient if she had more serious disease activity such as nephritis or if her arthritis or pericarditis recurred while taking hydroxychloroquine. NSAIDs, often with colchicine, are first-line therapy for most patients with pericarditis, although glucocorticoids may be indicated in patients with pericarditis associated with a systemic inflammatory disease such as in this patient. However, there is no indication to start an NSAID now given resolution of her symptoms, and doing so would increase her risk of gastrointestinal complications if used along with her daily glucocorticoid. Key Point Antimalarial therapy such as hydroxychloroquine in systemic lupus erythematosus (SLE) has documented benefit for reducing disease activity, improving survival, and reducing the risk of SLE-related thrombosis and myocardial infarction. Bibliography Lee SJ, Silverman E, Bargman JM. The role of antimalarial agents in the treatment of SLE and lupus nephritis. Nat Rev Nephrol. 2011 Oct 18;7(12):718-29. MKSAP 17 Question 2 A 35-year-old woman is evaluated for weakness in the right foot and left wrist with paresthesia in the right leg, right foot, left forearm, and left hand. She also reports facial erythema and joint stiffness. She has a 6-year history of systemic lupus erythematosus (SLE). Medications are hydroxychloroquine, prednisone, vitamin D, and calcium. On physical examination, vital signs are normal. There is a new malar rash. Swelling of the second through fourth metacarpophalangeal joints of the hands is present. There is dorsiflexion weakness of the right ankle and a left wrist drop. Reflexes are normal. The remainder of the examination is normal. Laboratory studies indicate that her SLE appears to be active with an elevation of erythrocyte sedimentation rate compared with baseline, leukopenia, and anemia typical of her previous SLE flares. Which of the following is the most appropriate next step in management? A. Discontinue hydroxychloroquine B. Obtain electromyography/nerve conduction studies C. Obtain MRI of the cervical spine D. Obtain skin biopsy for small-fiber neuropathy Correct Answer B. Obtain electromyography/nerve conduction studies Educational Objective Evaluate a patient with systemic lupus erythematosus who has developed mononeuritis multiplex. Critique Electromyography (EMG) and nerve conduction studies (NCS) are appropriate for this patient with systemic lupus erythematosus (SLE) who most likely has mononeuritis multiplex. Mononeuritis multiplex is characterized by abnormal findings in the territory of two or more nerves in separate parts of the body. She has a foot drop with normal reflexes that suggests an injury to the peroneal nerve and wrist drop that suggests injury to the radial nerve. EMG/NCS would most likely document a peripheral neuropathy. Mononeuritis multiplex is highly specific for vasculitic disorders that affect the vasa vasorum or nerve vascular supply but can also occur in systemic inflammatory disorders such as SLE. The peroneal nerve is the most commonly affected nerve. Approximately 14% of patients with SLE have a peripheral neuropathy with the majority (60%) due to SLE. Risk factors for the development of SLE-associated peripheral neuropathy include moderate to severe disease and the presence of other neuropsychiatric SLE manifestations. Approximately two thirds of patients improve with more aggressive immunosuppression. EMG/NCS can identify a nerve (usually the sural nerve) that might be amenable to biopsy to document the vasculitis prior to aggressive immunosuppression. Hydroxychloroquine can cause a neuromyopathy manifested by proximal muscle weakness and areflexia. Biopsy demonstrates vacuoles in the muscle cells. However, hydroxychloroquine has not been associated with mononeuritis multiplex. SLE may rarely cause transverse myelitis, which is characterized by a rapidly progressing paraparesis associated with a sensory level. Autonomic symptoms, including increased urinary urgency, bladder and bowel incontinence, and sexual dysfunction, may be present. The patient has no symptoms suggesting transverse myelitis, and a spine MRI is not indicated. A small-fiber neuropathy causes a burning pain in the extremities and has been associated with autoimmune diseases such as SLE but does not cause motor symptoms. Diagnosis is made by skin biopsy, which demonstrates a reduced density of small sensory nerve fibers in the skin. Key Point Mononeuritis multiplex is characterized by abnormal findings in the territory of two or more nerves in separate parts of the body and is highly specific for vasculitis but can occur in systemic inflammatory disorders such as systemic lupus erythematosus. Bibliography Florica B, Aghdassi E, Su J, et al. Peripheral neuropathy in patients with systemic lupus erythematosus. Semin Arthritis Rheum. 2011 Oct;41(2):203-11. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Pharmacologic Treatment of Seasonal Allergic Rhinitis: Synopsis of Guidance From the 2017 Joint Task Force on Practice Parameters Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-28 Dana V. Wallace, Mark S. Dykewicz, John Oppenheimer, Jay M. Portnoy, David M. Lang
Description: The Joint Task Force on Practice Parameters, which comprises representatives of the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), formed a workgroup to review evidence and provide guidance to health care providers on the initial pharmacologic treatment of seasonal allergic rhinitis in patients aged 12 years or older. Methods: To update a prior systematic review, the workgroup searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 18 July 2012 to 29 July 2016 to identify studies that addressed efficacy and adverse effects of single or combination pharmacotherapy for seasonal allergic rhinitis. In conjunction with the Joint Task Force, the workgroup reviewed the evidence and developed recommendations about initial treatment approaches by using the Grading of Recommendations Assessment, Development and Evaluation approach. Members of the AAAAI, the ACAAI, and the general public provided feedback on the draft document, which the Joint Task Force reviewed before finalizing the guideline. Recommendation 1: For initial treatment of seasonal allergic rhinitis in persons aged 12 years or older, routinely prescribe monotherapy with an intranasal corticosteroid rather than an intranasal corticosteroid in combination with an oral antihistamine. (Strong recommendation) Recommendation 2: For initial treatment of seasonal allergic rhinitis in persons aged 15 years or older, recommend an intranasal corticosteroid over a leukotriene receptor antagonist. (Strong recommendation) Recommendation 3: For treatment of moderate to severe seasonal allergic rhinitis in persons aged 12 years or older, the clinician may recommend the combination of an intranasal corticosteroid and an intranasal antihistamine for initial treatment. (Weak recommendation)
Management of Suspected Opioid Overdose With Naloxone in Out-of-Hospital Settings: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-28 Roger Chou, P. Todd Korthuis, Dennis McCarty, Phillip O. Coffin, Jessica C. Griffin, Cynthia Davis-O'Reilly, Sara Grusing, Mohamud Daya
Background: Naloxone is effective for reversing opioid overdose, but optimal strategies for out-of-hospital use are uncertain. Purpose: To synthesize evidence on 1) the effects of naloxone route of administration and dosing for suspected opioid overdose in out-of-hospital settings on mortality, reversal of overdose, and harms, and 2) the need for transport to a health care facility after reversal of overdose with naloxone. Data Sources: Ovid MEDLINE (1946 through September 2017), PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL, U.S. Food and Drug Administration (FDA) materials, and reference lists. Study Selection: English-language cohort studies and randomized trials that compared different doses of naloxone, administration routes, or transport versus nontransport after reversal of overdose with naloxone. Main outcomes were mortality, reversal of overdose, recurrence of overdose, and harms. Data Extraction: Dual extraction and quality assessment of individual studies; consensus assessment of overall strength of evidence (SOE). Data Synthesis: Of 13 eligible studies, 3 randomized controlled trials and 4 cohort studies compared different administration routes. At the same dose (2 mg), 1 trial found similar efficacy between higher-concentration intranasal naloxone (2 mg/mL) and intramuscular naloxone, and 1 trial found that lower-concentration intranasal naloxone (2 mg/5 mL) was less effective than intramuscular naloxone but was associated with decreased risk for agitation (low SOE). Evidence was insufficient to evaluate other comparisons of route of administration. Six uncontrolled studies reported low rates of death and serious adverse events (0% to 1.25%) in nontransported patients after successful naloxone treatment. Limitation: There were few studies, all had methodological limitations, and none evaluated FDA-approved autoinjectors or highly concentrated intranasal formulations. Conclusion: Higher-concentration intranasal naloxone (2 mg/mL) seems to have efficacy similar to that of intramuscular naloxone for reversal of opioid overdose, with no difference in adverse events. Nontransport after reversal of overdose with naloxone seems to be associated with a low rate of serious harms, but no study evaluated risks of transport versus nontransport. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42016053891)
Hepatitis B Vaccination, Screening, and Linkage to Care Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-21
Who developed these recommendations? The American College of Physicians (ACP) developed these recommendations with the Centers for Disease Control and Prevention (CDC). The ACP is a professional organization for internal medicine doctors, who specialize in health care for adults. The CDC is a U.S. government agency that promotes public health. What is the problem and what is known about it so far? Hepatitis B virus (HBV) infection spreads through contact with infected body fluids, such as by sexual contact, via contaminated needles, or from mother to baby at birth. Most people with HBV infection recover in a few months, but some develop chronic infection, permanent liver damage (cirrhosis), or liver cancer. Vaccination with a series of 3 shots over 6 months prevents HBV infection. Screening for HBV infection with a blood test identifies people with chronic infection who may benefit from earlier care, including drugs that decrease the chance of liver damage and screening for liver cancer. How did the ACP and the CDC develop these recommendations? The authors looked at guidelines from other organizations and studies related to best practices for HBV vaccination, screening, and linkage to care. They used this information to develop recommendations that the ACP and the CDC agreed would be best for patients. What do the ACP and the CDC suggest that patients and doctors do? The ACP and the CDC recommend HBV vaccination for people who request it and for unvaccinated adults (including pregnant women) at risk for infection, including: • Sexual partners of people with HBV infection • People who have many sex partners • People with a history of sexually transmitted infections (STIs) • Men who have sex with men • Injection drug users • People who live with someone who has HBV infection • Health care and public safety workers who may come into contact with blood • People with diseases that make their immune system weak, such as advanced kidney disease, chronic liver disease, or HIV • People traveling to places with high rates of HBV infection • People who work at or regularly visit jails, prisons, treatment facilities for STIs or drug abuse, day care centers for developmentally disabled people, or programs for end-stage kidney disease The ACP and the CDC recommend screening for HBV in adults who are at risk, including people born in countries with high HBV infection rates, men who have sex with men, injection drug users, household or sexual contacts of HBV-infected people, users of drugs that suppress the immune system, people with end-stage kidney disease, blood and tissue donors, people infected with hepatitis C virus, people with persistently abnormal liver test results, and incarcerated populations. Pregnant women and infants born to infected women should be screened. Doctors should speak with HBV-infected patients about possible treatment and care options. Patients should be referred to HBV-specific medical care and counseling programs. Not all patients with HBV infection need treatment. Questions you may want to ask your doctor • Should I get the HBV vaccine? • How do I find out if I ever got the vaccine? • Should I be screened for HBV? • If I think I have been exposed to HBV, what should I do? • If I have HBV infection, what are my treatment options and what can I do to prevent others from getting it?
Annals for Hospitalists - 21 November 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-21 David H. Wesorick, Vineet Chopra
Inpatient Notes The Other Catheter—the Mighty Peripheral IV —Claire M. Rickard, RN, PhD, and Nicole M. Marsh, RN, MAppPrac (HealthRes) The peripheral intravenous catheter is one of the most important and prevalent medical devices in the hospital, so why have quality improvement efforts neglected this device? The authors of this issue's Inpatient Notes argue that it's time to improve this staple of inpatient care. Highlights of Recent Articles From Annals of Internal Medicine In the Clinic: Acute Kidney Injury Ann Intern Med. 2017;167:ITC66-ITC80. doi:AITC201711070 In this narrative review article, the authors provide an overview of the diagnosis, prevention, and treatment of acute kidney injury (AKI). Key points for hospitalists include: Acute kidney injury occurs in about 20% of hospitalized patients, most commonly in older patients and those with underlying chronic kidney disease. About 10% of hospitalized patients with AKI require renal replacement therapy. There are many causes of AKI in hospitalized patients. Reduced renal perfusion (e.g., volume depletion, sepsis, and heart or liver failure) is a common cause of AKI in patients presenting for hospital admission. Acute tubular necrosis is the most common hospital-acquired cause. Medications can lead to AKI by causing acute tubular necrosis (e.g., radiocontrast, aminoglycosides, vancomycin, amphotericin B, cisplatin, carboplatin, iphosphamide), interstitial nephritis (e.g., β-lactams, sulfonamides), crystal nephropathy (e.g., methotrexate, acyclovir), or other insults (e.g., nonsteroidal anti-inflammatory drugs, angiotensin–converting enzyme inhibitors, angiotensin–receptor blockers, calcineurin inhibitors). Although loop diuretics can increase urine output in some cases of AKI, they do not seem to decrease mortality, the need for renal replacement therapy, or the time to renal recovery. Diagnostic Accuracy of Screening Tests and Treatment for Post—Acute Coronary Syndrome Depression: A Systematic Review Ann Intern Med. 2017;167:725-735. Published 14 November 2017. doi:10.7326/M17-1811 This systematic review (an update to a 2005 Agency for Healthcare Research and Quality review) analyzed 6 observational studies of screening for post–acute coronary syndrome (ACS) depression, and 4 randomized controlled trials (RCTs) for treatment of post-ACS depression. The review shows that available depression screening tools exhibit acceptable sensitivity, specificity, and negative predictive value in this population, although positive predictive values are low. Three of 4 studies of treatment showed a decrease in depressive symptoms with medications, psychotherapy, or both, although the clinical significance of the improvements was thought to be relatively minor. Key points for hospitalists include: Major depressive disorder is common after ACS, affecting up to 20% of patients. An even greater percentage of these patients have less-severe depression. Hospitalists should be on the lookout for this disorder. Existing depression screening tools seem to function adequately in this population, and treatment methods (such as medication and psychotherapy) do have a favorable effect on psychosocial outcomes. There is no evidence that these interventions improve cardiovascular outcomes. There is no evidence that screening for depression in this population improves outcomes, and guidelines differ on whether they do or do not recommend it. Predicting 30-Day Mortality for Patients With Acute Heart Failure in the Emergency Department: A Cohort Study Ann Intern Med. 2017;167:698-705. Published 3 October 2017. doi:10.7326/M16-2726 In this prospective cohort study, investigators analyzed clinical variables and 30-day mortality in patients presenting to 34 Spanish emergency departments with acute heart failure in order to derive (4867 patients) and validate (3229 patients) a risk score to predict 30-day mortality. The resulting model used 13 clinical variables (including age, vital signs, laboratory values, and the Barthel index score) to stratify risk for 30-day mortality and achieved good discrimination (a mortality rate of <2% with scores in the lowest 2 quintiles vs. a mortality rate of 45% for those with scores in the highest decile). The c-statistic in the validation group was 0.828, indicating good model performance. Key points for hospitalists include: The authors suggest that clinical decisions in patients with acute heart failure (e.g., deciding which patients require hospital admission) are often made without any formal risk assessment, resulting in an inability to match the intensity of care to the risk for mortality. The model described in this paper appears to have good discrimination of risk in this population and may allow clinicians to better estimate mortality risk in patients with acute heart failure. An accompanying editorial suggests that the model will require further validation in diverse populations. If it is able to identify a large group of low-risk patients presenting to the emergency department, the next challenge may be understanding how to best manage these patients outside of the hospital. The Latest Highlights From ACP Journal Club Are antibiotics beneficial after incision and drainage of a small abscess? In small skin abscesses, clindamycin or trimethoprim-sulfamethoxazole after incision and drainage increased cures Ann Intern Med. 2017;167:JC39. doi:10.7326/ACPJC-2017-167-8-039 This study randomly assigned 786 children and adults with small skin abscesses (≤5 cm in diameter in adults, smaller in children) and without fever, systemic inflammatory response syndrome, or immunocompromise to receive clindamycin, trimethoprim–sulfamethoxazole (TMP-SMX), or placebo for 10 days after incision and drainage of the abscess. Either treatment resulted in statistically significantly higher clinical cure rates than placebo at 7 to 10 days (clindamycin, 83%; TMP-SMX, 82%; placebo, 69%) and at 30 days (clindamycin, 79%; TMP-SMX, 73%; placebo, 63%). Clindamycin use was associated with significantly higher rates of diarrhea than TMP-SMX or placebo. Is it beneficial to add TMP-SMX to cephalexin when treating nonpurulent cellulitis? Adding trimethoprim-sulfamethoxazole to cephalexin did not increase clinical cure in uncomplicated cellulitis Ann Intern Med. 2017;167:JC40. doi:10.7326/ACPJC-2017-167-8-040 In this study, 500 adults with cellulitis, without abscess or purulent drainage (confirmed by ultrasound evaluation), and without immunocompromise or intravenous drug use were randomly assigned to receive cephalexin plus TMP-SMX or cephalexin alone for 7 days. The addition of TMP-SMX did not improve outcomes, including rates of cure, hospitalization, or surgical procedures. These findings support the observation that Staphylococcus aureus is an uncommon cause of nonpurulent cellulitis. Is triple therapy more effective than oseltamivir monotherapy for severe influenza infection? Triple therapy reduced mortality more that oseltamivir alone in patients admitted for severe influenza infection Ann Intern Med. 2017;167:JC41. doi:10.7326/ACPJC-2017-167-8-041 This RCT compared 30-day mortality in 217 adults (median age 80 to 82 years) who were hospitalized for severe influenza A infection with evidence of fever and chest infiltrate. Patients were randomly assigned to receive either triple therapy (clarithromycin, naproxen, and oseltamivir) or oseltamivir alone. Patients receiving triple therapy had significantly lower mortality at 30 days (0.9% vs. 8.2%, respectively) and 90 days (1.9% vs. 10%, respectively). Does the long-term use of azithromycin improve outcomes in asthma with uncontrolled symptoms despite maintenance inhaler treatment? Azithromycin reduced exacerbations and improved QoL in symptomatic asthma despite inhaled maintenance therapy Ann Intern Med. 2017;167:JC42. doi:10.7326/ACPJC-2017-167-8-042 This RCT examined 420 adult patients with symptomatic asthma despite the use of maintenance inhaled corticosteroids or long-acting bronchodilators. Patients were randomly assigned to either oral azithromycin (500 mg 3 times/wk) or placebo for 48 weeks. Patients receiving azithromycin had significantly fewer moderate and severe exacerbations (relative risk reduction, 25%; 95% CI, 10 to 38) and higher asthma-related quality-of-life scores (although the latter are of doubtful clinical significance). How azithromycin might compare with other adjunctive therapies for persistently symptomatic asthma (e.g., additional inhaled therapy, a leukotriene inhibitor, or a biologic) remains unclear and a topic of future inquiry. Sign up here to have Annals for Hospitalists delivered to your inbox each month.
Annals for Educators - 21 November 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-21 Darren B. Taichman
Clinical Practice Points Self-administered Versus Directly Observed Once-Weekly Isoniazid and Rifapentine Treatment of Latent Tuberculosis Infection. A Randomized Trial Expanding treatment for latent tuberculosis infection (LTBI) is important to decrease active disease globally. This study compared treatment completion and safety of self-administered once-weekly isoniazid and rifapentine versus direct observation. Use this study to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners who should be screened for LTBI. How should screening be performed? What are the treatment options? Use the recent In the Clinic: Tuberculosis to help prepare your teaching session. What are the risks and benefits of each directly observed and self-administered treatment for LTBI? Do your learners believe they can identify patients in whom self-administered treatment would be appropriate? What were the inclusion and exclusion criteria for this randomized trial? Do they help guide you? Oral Human Papillomavirus Infection: Differences in Prevalence Between Sexes and Concordance With Genital Human Papillomavirus Infection, NHANES 2011 to 2014 The prevalence of human papillomavirus (HPV)–positive oropharyngeal cancer is disproportionately high among men. Data from the National Health and Nutrition Examination Survey (2011 to 2014) were used to determine the prevalence of oral HPV infection and the concordance of oral and genital HPV infection among U.S. men and women. This information is critical for designing detection and prevention efforts. Use this study to: Ask your learners who is at increased risk for HPV infection. Is screening recommended? In whom, and how? What are the potential complications of HPV infection? Are your learners surprised by the prevalence estimates for HPV infection among men and women? What are the recommendations for HPV vaccination? Consult the most recent statement from the Advisory Committee on Immunization Practices. Until what age are men and women to receive vaccination? Might the data from this study be useful in assessing the appropriateness of current recommendations? Annals for Hospitalists Inpatient Notes - The Other Catheter—the Mighty Peripheral IV Peripheral intravenous catheters (PIVCs) are among the most important and prevalent medical devices in the hospital. However, they have received limited attention in the context of patient safety and health care quality. Substantial attention has been paid to the 3 million central venous catheters placed annually in the United States. The author discusses the relatively limited attention paid to the more than 350 million PIVCs placed. Use this paper to: Ask your learners what your hospital's policy is on the need for PIVCs in inpatients. Are they required for everyone? Are they routinely changed after a set number of days, or only when they are nonfunctional? Does everyone need a PIVC? Are they harmless? Do your learners think current practice could be improved? What changes would they consider? What additional information would be desired before making a change? Can your learners propose practical means to gather this information or to study a change in practice? Working in Our Health Care System Novel Metrics for Improving Professional Fulfillment Myriad financial, quality, and service metrics pervade the professional lives of ambulatory care providers. These include measurements from the electronic health record (EHR), which include practice efficiency scores that create a window on the clinician's workflow. In this article, the authors propose a set of EHR-related metrics that provide further insight into the clinician experience. Use this paper to: Ask your learners whether they like or dislike using your system's EHR. What are the potential benefits of using an EHR? What are the risks to patients and the burdens on health care providers? Can your learners propose ways to minimize or eliminate these risks and burdens? Do your learners think the “metrics” proposed by the authors of this paper would be useful? What needs to be agreed on regarding how a metric will be used before it is worth measuring it? Invite a member of your hospital's administration who is responsible for EHR implementation to join your discussion. Ask what metrics your system uses to evaluate how well your EHR functions. Do your learners believe the right areas are being scrutinized? Video Learning Annals Consult Guys - Fasting Before Anesthesia: A Cappuccino on Call? Howard and Geno (the Consult Guys) help decide whether a procedure requiring anesthesia may proceed after a patient drank a cappuccino. Use this feature to: Take a relaxing and educational break with your learners and watch this 10-minute video. Ask your learners what the policy is regarding fasting before procedures at your center. What are these policies based on? What are the risks of having food or liquid before anesthesia, and how long do they last? Answer the multiple-choice questions with your team. Log on and submit your own answers to earn CME/MOC credit for yourself. Humanism and Professionalism On Being a Doctor: 2:32 a.m. Dr. Waxman notes that the rewards of helping a patient in the middle of the night come at a price to his family. Use this essay to: Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Ask your learners if they resent when time caring for patients takes away from time with family and friends. How do they deal with this resentment? Does patient care seem like an inconvenience? Do any of your learners have children? Do they think the pressures are different in this situation? What other unique situations do your learners face? How do we balance work and family responsibilities? Do we talk to our family and friends about these challenges? Do they understand? MKSAP 17 Question A 30-year-old woman is evaluated for a reactive tuberculin skin test (TST). She developed 6-mm induration 48 hours after the test was performed. She has no fever, weight loss, or cough, and cannot recall any exposure to tuberculosis. Medical history is notable for psoriasis diagnosed 10 years ago. Her only medication is infliximab. A TST result was negative before initiation of therapy. On physical examination, vital signs are normal. Stable plaque psoriasis is noted. The lungs are clear, and the remainder of the examination is normal. Which of the following is the most appropriate next step in the management of this patient? A. Chest radiography B. Interferon-γ release assay C. Rifampin, isoniazid, pyrazinamide, and ethambutol D. No further intervention Correct Answer A. Chest radiography Educational Objective Manage a reactive tuberculin skin test in an immunosuppressed patient. Critique This patient should undergo chest radiography to exclude active tuberculosis infection. The patient is asymptomatic and is taking infliximab, a tumor necrosis factor α inhibitor, for management of her psoriasis. A tuberculin skin test (TST) reaction of 5-mm or larger induration is interpreted as positive in patients who are immunosuppressed, including those who are taking tumor necrosis factor α inhibitors or the equivalent of at least 15 mg/d of prednisone for 1 month or longer. Other patients for whom 5-mm or larger induration is considered positive include patients with HIV infection, organ transplants, and fibrotic changes on chest radiograph consistent with old tuberculosis, and recent contacts of a person with active tuberculosis. If the chest radiograph is negative, treatment for latent tuberculosis infection, usually consisting of daily isoniazid with pyridoxine (vitamin B6) for 9 months, is recommended to decrease the risk for progression to active disease. Testing with both the TST and interferon-γ release assay is not routinely recommended. According to the Centers for Disease Control and Prevention, using both tests may be helpful when the result of the initial test is positive and additional validation of infection is required before recommended treatment is initiated, such as in health care professionals who previously received the bacillus Calmette-Guérin vaccine or patients at low risk for infection and progression to active disease. Conversely, both tests may be helpful when the result of the initial test is negative and the risk for infection, active disease, and a poor outcome is increased, such as in patients infected with HIV or children younger than 5 years who have been exposed to a patient with active tuberculosis. Using both tests also may be helpful when the result of the initial test is negative but symptoms, signs, or imaging results are suspicious for TB and evidence of infection with M. tuberculosis is being sought. Because this patient does not fit into one of these categories, interferon-γ release assay would not be indicated. Rifampin, isoniazid, pyrazinamide, and ethambutol would be recommended as initial therapy for a patient with active tuberculosis. This patient has no symptoms of active infection. Unless the chest radiograph suggests active tuberculosis, beginning four-drug antituberculous therapy is not indicated and would not be appropriate before further evaluation. No additional intervention, including evaluation or therapy, would be inappropriate for this patient. Although she is asymptomatic, she is at risk for active tuberculosis if untreated for latent tuberculosis infection. Key Point Patients who have a positive reaction to tuberculin skin testing should be further evaluated by chest radiography to rule out active tuberculosis infection. Bibliography Centers for Disease Control and Prevention. Latent Tuberculosis Infection: A Guide for Primary Health Care Providers. Updated November 26, 2014. Accessed July 21, 2015. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Annals Consult Guys - Fasting Before Anesthesia: A Cappucino On Call? Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-21 Geno J. Merli, Howard H. Weitz
Howard and Geno (the Consult Guys) help decide whether a procedure requiring anesthesia may proceed after a patient drank a cappuccino. For more videos from and information on Annals Consult Guys, visit go.annals.org/ConsultGuys.
Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-21 Winston E. Abara, Amir Qaseem, Sarah Schillie, Brian J. McMahon, Aaron M. Harris
Background: Vaccination, screening, and linkage to care can reduce the burden of chronic hepatitis B virus (HBV) infection. However, recommendations vary among organizations, and their implementation has been suboptimal. The American College of Physicians' High Value Care Task Force and the Centers for Disease Control and Prevention developed this article to present best practice statements for hepatitis B vaccination, screening, and linkage to care. Methods: A narrative literature review of clinical guidelines, systematic reviews, randomized trials, and intervention studies on hepatitis B vaccination, screening, and linkage to care published between January 2005 and June 2017 was conducted. Best Practice Advice 1: Clinicians should vaccinate against hepatitis B virus (HBV) in all unvaccinated adults (including pregnant women) at risk for infection due to sexual, percutaneous, or mucosal exposure; health care and public safety workers at risk for blood exposure; adults with chronic liver disease, end-stage renal disease (including hemodialysis patients), or HIV infection; travelers to HBV-endemic regions; and adults seeking protection from HBV infection. Best Practice Advice 2: Clinicians should screen (hepatitis B surface antigen, antibody to hepatitis B core antigen, and antibody to hepatitis B surface antigen) for HBV in high-risk persons, including persons born in countries with 2% or higher HBV prevalence, men who have sex with men, persons who inject drugs, HIV-positive persons, household and sexual contacts of HBV-infected persons, persons requiring immunosuppressive therapy, persons with end-stage renal disease (including hemodialysis patients), blood and tissue donors, persons infected with hepatitis C virus, persons with elevated alanine aminotransferase levels (≥19 IU/L for women and ≥30 IU/L for men), incarcerated persons, pregnant women, and infants born to HBV-infected mothers. Best Practice Advice 3: Clinicians should provide or refer all patients identified with HBV (HBsAg-positive) for posttest counseling and hepatitis B–directed care.
Functional Impairment and Decline in Middle Age Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-14
What is the problem and what is known about it so far? To live independently, people must be able to do basic activities of daily living (ADLs), such as taking a bath, putting on clothes, or getting out of a chair or bed, without help from another person. The inability to perform ADLs, also known as “functional impairment,” is common in older adults. Studies suggest that functional impairment is also common in middle-aged adults. It is not clear how many middle-aged adults have functional limitations. For those who have problems with ADLs, it is also unclear how long these problems last. Why did the researchers do this particular study? To determine the proportion of middle-aged adults in whom a new functional limitation developed and whether the problem got better, got worse, or stayed the same. Who was studied? 6874 middle-aged adults who were living in the community. These adults did not have problems performing ADLs when they entered the study. How was the study done? The study participants were interviewed by telephone at baseline and every 2 years. At each interview, they were asked whether they had any problems doing basic ADLs, and they answered questions about their general health, medical conditions, and health behaviors. The researchers examined how many participants had a new functional impairment during follow-up. For participants in whom impairment developed, the researchers described those whose impairment got better, those whose impairment got worse, and those whose impairment stayed the same. What did the researchers find? Difficulty with at least 1 ADL developed in about 1 in 4 participants between the ages of 50 and 64 years. Two years after functional impairment developed, 50% of participants continued to have limitations and 37% recovered. In 9%, the impairment worsened, and 4% died. During 10 years of follow-up, 28% of participants recovered from their initial episode and remained independent, whereas about 20% had further episodes, with worsening functional impairment, and 19% died. What were the limitations of the study? The information provided by the participants on their activity limitations was not verified objectively. What are the implications of the study? Functional impairment, or difficulty doing basic ADLs, is common during middle age. Of the middle-aged adults in whom a functional limitation developed, some had further impairment or died during follow-up. These findings suggest that functional impairment may not be a short-term problem during middle age.
Diagnostic Accuracy of Screening Tests and Treatment for Post–Acute Coronary Syndrome Depression: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-14 Jason A. Nieuwsma, John W. Williams, Natasha Namdari, Jeffrey B. Washam, Giselle Raitz, James A. Blumenthal, Wei Jiang, Roshini Yapa, Amanda J. McBroom, Kathryn Lallinger, Robyn Schmidt, Andrzej S. Kosinski, Gillian D. Sanders
Background: Patients who have had an acute coronary syndrome (ACS) event have an increased risk for depression. Purpose: To evaluate the diagnostic accuracy of depression screening instruments and to compare safety and effectiveness of depression treatments in adults within 3 months of an ACS event. Data Sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Database of Systematic Reviews from January 2003 to August 2017, and a manual search of citations from key primary and review articles. Study Selection: English-language studies of post-ACS patients that evaluated the diagnostic accuracy of depression screening tools or compared the safety and effectiveness of a broad range of pharmacologic and nonpharmacologic depression treatments. Data Extraction: 2 investigators independently screened each article for inclusion; abstracted the data; and rated the quality, applicability, and strength of evidence. Data Synthesis: Evidence from 6 of the 10 included studies showed that a range of depression screening instruments produces acceptable levels of diagnostic sensitivity, specificity, and negative predictive values (70% to 100%) but low positive predictive values (below 50%). The Beck Depression Inventory-II was the most studied tool. A large study found that a combination of cognitive behavioral therapy (CBT) and antidepressant medication improved depression symptoms, mental health–related function, and overall life satisfaction more than usual care. Limitation: Few studies, no evaluation of the influence of screening on clinical outcomes, and no studies addressing several clinical interventions of interest. Conclusion: Depression screening instruments produce diagnostic accuracy metrics that are similar in post-ACS patients and other clinical populations. Depression interventions have an uncertain effect on cardiovascular outcomes, but CBT combined with antidepressant medication produces modest improvement in psychosocial outcomes. Primary Funding Source: Agency for Healthcare Research and Quality (PROSPERO: CRD42016047032).
Annals Story Slam - Wonder Woman Is a Cartoon Character Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Ana Maria Lopez
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Lopez relays her story of balancing doctoring and parenting. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - What I Learned From Madame Secretary, Notorious RBG, and Nana Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Darilyn V. Moyer
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Moyer relays her story of balancing doctoring and parenting. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - Pay Your Nanny Well Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Heather E. Gantzer
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Gantzer relays her story of balancing doctoring and parenting. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - How Wonder Woman Became My Alter Ego Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Susan Thompson Hingle
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Hingle relays her story of balancing doctoring and parenting. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - Dr. Mom Gets Sick Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Jacqueline W. Fincher
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Fincher relays her story of balancing doctoring and parenting. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - Becoming Dr. Mom Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Rebecca Masters
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Masters relays her story of balancing doctoring and parenting. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - A Missed Opportunity Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Carrie A. Horwitch
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Horwitch relays her story of balancing doctoring and parenting. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals for Educators - 7 November 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Darren B. Taichman
Clinical Practice Points Discontinuing Inappropriate Medication Use in Nursing Home Residents. A Cluster Randomized Controlled Trial Inappropriate prescribing of medications is a common problem associated with increased risk for adverse outcomes in older adults. This randomized controlled trial examined the effect of a multidisciplinary medication review performed by physicians and pharmacists on the discontinuation of inappropriate medication use and clinical outcomes among nursing home residents. Use this paper to: Start a teaching session with a multiple-choice question. We've provided one below! Teach at the bedside! Review with your team the admitting medication list of several nursing home residents on your service. Are the lists long? Are all of the drugs necessary? Do any present potential problems? Ask your learners how they would define polypharmacy. In what ways might it lead to adverse events? The authors address these issues in the introduction to their study. Need the list be long for it to include inappropriate drugs? Review the intervention used in this cluster randomized controlled trial (Table 1). Who was involved? How were medications assessed? How well do your learners think they can assess the appropriateness of each medication for all of their patients? Ask them to do so for each of the patients on their service (or each of the outpatients they see) before your next meeting. Did they identify any potentially inappropriate drugs? Ask whether your learners ever leave patients on drugs they do not think or are not sure are needed. Are they hesitant to discontinue drugs they did not prescribe? How should they approach this issue? To whom should they talk? Who reviews a patient's discharge medication list at your hospital? Look at the Annals Graphic Medicine piece described below. How do patients end up using long lists of medicines they no longer need? Ask what a cluster randomized trial is. How does it differ from more traditional clinical trials? What is the unit of randomization in each? How does this difference influence what may be learned? This study did not find a difference in the secondary outcomes that were assessed. The authors note that the trial was not powered to assess them. What does it mean if a study is “underpowered”? Look at the 95% confidence intervals around the point estimates for the secondary outcomes (Table 4). How should they be interpreted? Why might the study have found only modest effects? Use the accompanying editorial to help frame your discussion. The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension. A Cohort Study Primary aldosteronism is the most common and modifiable form of secondary hypertension and is usually considered when the classic phenotype of severe hypertension or hypokalemia is encountered. This study assessed whether a spectrum of subclinical primary aldosteronism that increases risk for hypertension exists among normotensive persons. Use this study to: Ask your learners which patients require an evaluation for secondary causes of hypertension. What should the evaluation include? Use In the Clinic: Hypertension to quickly find answers. What are the presenting signs and symptoms of primary aldosteronism? How is it currently diagnosed? Use the information in DynaMed Plus: Primary Aldosteronism (a benefit of your ACP membership). Review with your learners the regulation of renin and aldosterone. How is urinary sodium affected by renin and aldosterone concentrations? Invite a nephrologist to join your discussion. Review the key results of this study. The authors suggest that a state of clinically relevant renin-independent aldosteronism might be common and could affect the risk for subsequent cardiovascular disease. Do your learners think that we should test normotensive patients for this? What additional studies would they want before adopting such a practice? Use the accompanying editorial to help inform your discussion. Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus This synopsis summarizes key features of the 2017 joint clinical practice guideline from the U.S. Department of Veterans Affairs and the U.S. Department of Defense for the management of type 2 diabetes mellitus. Use this guideline synopsis to: Go down the list of recommendations in Table 1 with your team. Check off items your learners believe they should address with each of their diabetic patients. How would they assess whether they are doing these things? Can your EHR help? Should they review the charts of several of their own patients? Does your practice have a telehealth system available to improve the care of patients with diabetes? What members of the health care team are available to assist in providing diabetes care? The authors discuss the importance of individualizing glycemic goals according to patients' risks, life expectancy, personal goals, and other variables. How should each of these be considered when determining glycemic goals? Do your learners know how to discuss them with patients when choosing a goal, and what questions to ask? The authors discuss how their guideline differs from others. Why do glycemic targets differ in this manner? Use the accompanying editorial to help frame your discussion. Does your institution have protocols for inpatient glycemic control among diabetic patients? What do the authors recommend? Why don't they recommend as tight control for patients outside the ICU compared with those in the ICU? The authors recommend a “basal–bolus-plus-correction” approach to care outside the ICU but note that many inpatients are managed only with “correction” doses of insulin on a sliding-scale basis. What is the difference? What is done at your center, and why? In the Clinic In the Clinic: Acute Kidney Injury Acute kidney injury (AKI) occurs in approximately 20% of hospitalized patients, with major complications that include volume overload, electrolyte disorders, uremic complications, and drug toxicity. Are your learners prepared to prevent and manage AKI? Use this feature to: Ask your learners to list risk factors for AKI. Compare their list with the one provided in the Box. What measures are effective at preventing AKI, and in which patients should they be used? What are the major causes of AKI? Review Figure 2 with your learners. What features help distinguish between decreased kidney perfusion and acute tubular necrosis? List drugs that may cause AKI, and how. Use the information in the boxes for quick lists to help teach. Teach at the bedside (or microscope)! How do urinary tract findings help differentiate among the potential causes? Do your learners know how to assess urinary sediment? Take fresh samples of urine from patients on your service with AKI to the laboratory and review the sediment. Invite a nephrologist to help. Use the multiple-choice questions to introduce new topics for discussion in a teaching session. Download the teaching slides. Log in to answer the multiple-choice questions and claim CME/MOC credit for yourself! Comics and Medicine Annals Graphic Medicine - The “Problem” List Laugh (or cry?) as what starts as a simple issue evolves into a complex medical problem list. Use this feature to: Show the cartoon to your learners. Do they think there is truth to what the author depicts? What drives our medical system's desire to label everything? What practices can help to prevent needless labeling and inappropriate treatment of patients? How might this cartoon relate to the use of inappropriate medications addressed in the first study noted above? Humanism and Professionalism On Being a Patient: The Worst of Days Dr. Grinberg's horrible loss brings back the memories of a patient who was labeled as “crazy.” Use this essay to: Listen to an audio recording, read by Dr. Virginia Hood. Accept that sometimes discussion is not needed. Just listening together might be best. Consider asking if your learners worry that we sometimes brush aside a patient's suffering as mere “hysteria.” Do we sometimes worry about looking foolish for caring too much? MKSAP 17 Question A 90-year-old woman is brought to the emergency department by her son for a 1-week history of worsening cognition, weakness, dizziness, and anorexia. She lives in an assisted-care facility and is generally alert. She is ambulatory when using a cane. Medical history includes hypertension, chronic heart failure, chronic kidney disease, osteoarthritis, allergic rhinitis, hyperlipidemia, and urinary stress incontinence. Current medications are lisinopril, bisoprolol, oxybutynin, loratadine, acetaminophen, pravastatin, and omeprazole. On physical examination, she appears frail but is in no acute distress. Temperature is normal, blood pressure is 100/60 mm Hg, pulse rate is 88/min, and respiration rate is 14/min. BMI is 20. Oxygen saturation is 97% with the patient breathing ambient air. There is no orthostasis. Cardiac examination discloses an irregularly irregular rate. Pulmonary examination reveals slightly diminished breath sounds bilaterally but no crackles. The abdomen is mildly distended but nontender. Rectal examination reveals hard stool that is negative for occult blood. There is no edema. Neurologic examination is nonfocal, and the patient scores 24/30 on the Mini–Mental State Examination. Laboratory studies: Hematocrit 34% Leukocyte count 7100/µl (7.1 × 109/L); normal differential Creatinine 1.6 mg/dL (141 µmol/L) (2 months ago: 1.3 mg/dL [114 µmol/L]) Electrolytes Normal Glucose 78 mg/dL (4.3 mmol/L) Urinalysis Trace protein, trace ketones, no cells Hematocrit 34% Leukocyte count 7100/µl (7.1 × 109/L); normal differential Creatinine 1.6 mg/dL (141 µmol/L) (2 months ago: 1.3 mg/dL [114 µmol/L]) Electrolytes Normal Glucose 78 mg/dL (4.3 mmol/L) Urinalysis Trace protein, trace ketones, no cells Chest radiograph shows no evidence of heart failure or pulmonary infiltrates. Which of the following is the most likely cause of this patient's recent symptoms? A. Acute kidney injury B. Adverse medication effects C. Occult pneumonia D. Urinary tract infection Correct Answer B. Adverse medication effects Educational Objective Manage polypharmacy in an older patient. Critique This older patient's clinical findings are most likely the result of adverse medication effects related to polypharmacy, and her drug regimen requires adjustment. She has significant medical comorbidities and is taking numerous drugs. Administration of multiple medications increases the risk for inappropriate use, drug-drug interactions, adverse reactions, poor adherence, and medication errors. This patient is taking two anticholinergic agents (oxybutynin for urinary incontinence and the over-the-counter antihistamine loratadine). The American Geriatrics Society Beers Criteria recommend against the use of anticholinergic agents in older patients because they can cause confusion, urinary retention, constipation, and dry mouth. She is also on the proton pump inhibitor omeprazole without an apparent indication for treatment. In addition, the risk-to-benefit ratio of using a lipid-lowering agent to confer long-term benefits must be reassessed in very elderly adults. Prescriptions for statins are frequently carried over from previous years, but statin use results in additional cost, extra pills, and increased risk for drug-drug interactions. Lastly, parameters for blood pressure control are less stringent in older adults, and, in this patient, antihypertensive agents should be reassessed, as her hypertension is overtreated. Ongoing review of the indications, risks, benefits, and dosing of all drugs in older patients is recommended. This patient has a history of mild chronic kidney disease; however, with normal volume status, normal electrolytes, and a minimal change in her serum creatinine level, she does not have evidence of significant worsening of her kidney function. This would make acute kidney injury an unlikely cause of her current clinical findings. Infections are a frequent cause of systemic symptoms, including weakness, dizziness, anorexia, and altered mental status in older patients, with pneumonia and urinary tract infection being the most common types. However, this patient has no clinical findings consistent with pneumonia given her normal oxygenation, leukocyte count, and chest radiograph, or suggestion of urinary tract infection with a normal urinalysis. Therefore, the absence of evidence of infection makes this an unlikely cause of her current clinical findings. Key Point Administration of multiple medications, especially in older patients, increases the risk for inappropriate use, drug-drug interactions, adverse reactions, and medication errors. Bibliography Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57-65. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement Ann. Intern. Med. (IF 17.135) Pub Date : 2013-07-02
Who developed these guidelines? The U.S. Preventive Services Task Force (USPSTF) developed these recommendations. The USPSTF is a group of health experts that reviews published research and makes recommendations about preventive health care. What is the problem and what is known about it so far? HIV is the cause of AIDS, an illness that interferes with the body's ability to fight infection and some types of cancer. Treatments containing multiple drugs have improved outcomes for HIV-infected patients. The virus passes from person to person through contact with blood or other bodily fluids that contain it. People can have HIV infection for years before becoming sick. Men who have sex with men and active users of injected recreational drugs are at very high risk for HIV infection. Other risk factors include unprotected vaginal or anal intercourse; having sexual partners who are HIV-positive, bisexual, or injection drug users; exchanging sex for drugs or money; and having other sexually transmitted infections. Research also shows that people who request HIV testing despite reporting no risk factors are at increased risk for HIV infection, possibly because of risk factors that they do not report. Conventional tests for HIV infection are blood tests that usually provide results in 1 to 2 days. Rapid tests that provide results in 5 to 40 minutes involve testing blood or saliva, but positive results must be confirmed with conventional blood tests. In 2005, the USPSTF recommended that physicians ask patients about HIV risk factors, advise HIV testing for all adolescents and adults with a risk factor for HIV, and screen all pregnant women regardless of whether they have risk factors. Screening means testing people who feel well rather than waiting until symptoms develop. The USPSTF wanted to update these recommendations. How did the USPSTF develop these recommendations? The USPSTF reviewed published research to evaluate the benefits and harms of HIV screening. What did the authors find? Conventional and rapid HIV tests are highly accurate in diagnosing infection. Research shows that identification and treatment of HIV infection greatly reduce the progression to AIDS. Early initiation of treatment is associated with fewer AIDS-related complications or deaths. Treatment reduces the transmission of HIV to uninfected heterosexual partners. The identification and treatment of HIV infection in pregnant women greatly reduces the passage of infection from mother to child. The harms of screening for and treating HIV infection in adolescents, adults, and pregnant women are probably small. What does the USPSTF recommend that patients and doctors do? All adolescents and adults aged 15 to 65 years should have HIV screening. Younger adolescents and older adults who have risk factors for HIV infection should also be screened. All pregnant women should receive screening for HIV infection, including those who present in labor whose status is unknown. What are the cautions related to these recommendations? Patients with signs or symptoms of HIV infection should be tested regardless of whether they are in the aforementioned age and risk groups.
Firearm-Related Injury and Death: A U.S. Health Care Crisis in Need of Health Care Professionals Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-10 Darren B. Taichman, Howard Bauchner, Jeffrey M. Drazen, Christine Laine, Larry Peiperl
What would happen if on one day more than 50 people died and over 10 times that many were harmed by an infectious disease in the United States? Likely, our nation's esteemed and highly capable public health infrastructure would gear up to care for those harmed and study the problem. There would be a rush to identify the cause, develop interventions, and refine them continually until the threat is eliminated or at least contained. In light of the risks to public health (after all, over 500 people have been harmed already!), health care professionals would sound the alarm. We would demand funding. We would go to conferences to learn what is known and what we should do. We would form committees at our institutions to plan local responses to protect our communities. The United States would spend millions or more in short order to assure public safety, and no elected officials would conceive of getting in the way. Rather, they would compete to be calling the loudest for the funds and focus required to protect our people. Americans should be proud of our prowess at and commitment to addressing public health crises. Yet, here we are again with another editorial about the public health crisis of firearm-related injury and death following what used to be unthinkable, this time a mass murder and casualties at a concert in Las Vegas. We've written it all before. The staggering numbers killed annually. The numbers left permanently disabled. The families left to cope with the loss of loved ones or to care for those broken but not killed by a bullet. As health care professionals, we seem powerless. This public health crisis seems beyond the reach of our tools. Is there really nothing health care professionals can do? We think there is a lot. We need to each ask ourselves what we have done to apply our knowledge and skills to help address the problem since the moment of silence that followed the last mass shooting. More silence is not the answer. Have we demanded funding to adequately study the problem and test solutions? Have we participated in such studies? Have we mobilized forces at our institutions to plan strategies to lower the risks in our communities? Have we talked to our patients about gun safety and effectively challenged policies that would enforce our silence on this matter? Some of our colleagues have. We should be proud of them, but they need all of our help. And so do our patients. Here's a short list of how health care professionals can use our skills and voices to fight the threat that firearms present to health in the United States. Educate yourself. Read the background materials and proposals for sensible firearm legislation from health care professional organizations. Make a phone call and write a letter to your local, state, and federal legislators to tell them how you feel about gun control. Now. Don't wait. And do it again at regular intervals. Attend public meetings with these officials and speak up loudly as a health care professional. Demand answers, commitments, and follow-up. Go to rallies. Join, volunteer for, or donate to organizations fighting for sensible firearm legislation. Ask candidates for public office where they stand and vote for those with stances that mitigate firearm-related injury. Meet with the leaders at your own institutions to discuss how to leverage your organization's influence with local, state, and federal governments. Don't let concerns for perceived political consequences get in the way of advocating for the well-being of your patients and the public. Let your community know where your institution stands and what you are doing. Tell the press. Educate yourself about gun safety. Ask your patients if there are guns at home. How are they stored? Are there children or others at risk for harming themselves or others? Direct them to resources to decrease the risk for firearm injury, just as you already do for other health risks. Ask if your patients believe having guns at home makes them safer, despite evidence that they increase the risk for homicide, suicide, and accidents. Don't be silent. We don't need more moments of silence to honor the memory of those who have been killed. We need to honor their memory by preventing a need for such moments. As health care professionals, we don't throw up our hands in defeat because a disease seems to be incurable. We work to incrementally and continuously reduce its burden. That's our job. Will yet another commentary about the ravages of firearm-related harm change anything? Probably not—our journals have published far too many following prior firearm-enabled catastrophes. The only thing that will change the world for the better is a group of people who believe that they can change the world. With regard to firearm-related injury and death, let's each be part of that group. Darren B. Taichman, MD, PhD, Executive Deputy Editor, Annals of Internal Medicine Howard Bauchner, MD, Editor-in-Chief, JAMA (Journal of the American Medical Association) and the JAMA Network Jeffrey M. Drazen, MD, Editor-in-Chief, New England Journal of Medicine Christine Laine, MD, MPH, Editor in Chief, Annals of Internal Medicine Larry Peiperl, MD, Chief Editor, PLOS Medicine
Annals for Hospitalists - 17 October 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 David H. Wesorick, Vineet Chopra
Inpatient Notes Diagnostic Excellence Starts With an Incessant Watch —Gurpreet Dhaliwal, MD In this issue's Inpatient Notes, the author describes a simple yet powerful practice to develop and enhance one's diagnostic performance. Highlights of Recent Articles From Annals of Internal Medicine Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper Ann Intern Med. 2017;167:576-578. Published 19 September 2017. doi:10.7326/M17-0938 In this position paper, the American College of Physicians (ACP) states its formal position against the legalization of physician-assisted suicide, citing ethical, legal, and practical concerns. The authors argue that physician-assisted suicide violates the ethical tenets of beneficence and nonmaleficence. In addition, they express concern that physician participation in suicide could erode trust in the physician–patient relationship and fundamentally alter the role of the medical profession in society. Moreover, they recognize that a focus on facilitating death at the end of life might distract physicians from striving for the traditional goals of end-of-life care: relieving suffering and improving access to hospice and palliative care. Key points for hospitalists include: The ACP formally opposes the legalization of physician-assisted suicide. One editorial suggests that all physicians should firmly decline to participate in physician-assisted suicide, noting that it is simply not the duty of a physician. The author highlights uncertainties of the practice, including the identification of appropriate candidates and the challenges of creating reliable safeguards against misuse. He also argues that a patient's autonomy should not be considered absolute—indeed, physicians do not make decisions based solely on what patients want or request. Rather, medical decision making depends on the weighing of competing values, including the “intrinsic value of human life.” Another editorial suggests that physicians should not adopt a stance of rigid opposition to physician-assisted death. The authors recognize that most of the public favors legalization of physician-assisted suicide, even though physicians and some professional organizations are divided on the issue. The authors also suggest that now is the time to carefully study physician-assisted suicide, to debate its ethical implications, and to improve related processes and safeguards that serve the patients who choose this “last resort” option. Oregon's Death With Dignity Act: 20 Years of Experience to Inform the Debate Ann Intern Med. 2017;167:579-583. Published 19 September 2017. doi:10.7326/M17-2300 This article summarizes data from 20 years of experience with Oregon's Death With Dignity Act (DWDA), which allows physicians to legally prescribe lethal medications to terminally ill patients who want to end their own lives. During the past 20 years, 1857 Oregonians received prescriptions and 1179 died from ingesting them. About one third of the patients who obtained the prescriptions never took the medication. Of note, although the annual number of DWDA deaths has gradually increased over 20 years (16 deaths in 1998 vs. 136 deaths in 2016), it represents a small fraction of all deaths in the state. The median age of DWDA patients was 72 years—52% were men, 96% were white, and 72% had some college or higher education. Most DWDA patients had cancer (77%), and most (88%) were enrolled in hospice. During the first decade of implementation, 11% of DWDA patients had a formal psychiatric evaluation, but only 3% had been evaluated since. Key points for hospitalists include: A wealth of data about physician-assisted suicide is available from states and countries where the practice is legal, including Oregon. Analysis of these data can answer some important questions about the practice. Most patients cited loss of autonomy or inability to participate in activities that make life enjoyable as reasons for seeking DWDA prescriptions. Financial concerns were not frequently reported as motivating the request. Patients requesting DWDA prescriptions were only infrequently referred for psychiatric evaluations despite concerns that depression may be prevalent in this population. Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training Ann Intern Med. 2017;167:507-508. Published 12 September 2017. doi:10.7326/M17-0163 This Ideas and Opinions article suggests that the current health care environment may pose a threat to the cultivation of diagnostic reasoning skills in internal medicine trainees. Key points for hospitalists include: The current health care environment may undermine the emphasis on diagnostic reasoning in internal medicine training by demanding efficiency and pressuring trainees to “test (or even treat) first, think later.” Residents doing shiftwork are often unaware of the ultimate results of the diagnostic process they initiate and lack a clear feedback loop necessary to inform and refine diagnostic reasoning. The authors suggest that internal medicine training programs should act deliberately to preserve the development of diagnostic reasoning in these trainees. Possible solutions might include a renewed focus on diagnostic reasoning during teaching rounds and training conferences and efforts to ensure that trainees receive feedback about the outcomes of the diagnostic evaluations they initiate. For a related discussion, see this month's Inpatient Notes by Gurpreet Dhaliwal, MD. In the Clinic: Urinary Tract Infection Ann Intern Med. 2017;167:ITC49-ITC64. doi:AITC201710030 This narrative review provides an update of the evidence regarding diagnosis and treatment of urinary tract infections (UTIs). Key points for hospitalists include: Clinicians should not screen for or treat asymptomatic bacteriuria, except in pregnant patients or those undergoing invasive urinary procedures that will induce mucosal bleeding (e.g., transurethral resection of the prostate). Although UTI can be diagnosed clinically, urine culture should be done in patients in whom the diagnosis is uncertain, in pregnant women, and in men with suspected UTI. Urine culture is also indicated when pyelonephritis or complicated infection is suspected and in cases of relapse or treatment failure. Antibiotic choice depends on the classification of the disease. Fluoroquinolones should not be used to treat uncomplicated cystitis based on safety and stewardship concerns but may be used to treat pyelonephritis and complicated infections (e.g., structural abnormalities of the urinary tract or immunocompromised host). Resistance is common in many areas. The Latest Highlights From ACP Journal Club For older patients with chronic disease, do transitional care interventions reduce mortality or readmission rates? Review: In older patients with chronic disease, transitional care reduces mortality and readmissions Ann Intern Med. 2017;167:JC32. doi:10.7326/ACPJC-2017-167-6-032 This systematic review is the latest of many demonstrating the benefit of transitional care for older patients after hospital discharge. Transitional care provided care coordination and continuity, preplanned and structured follow-up after discharge, and ≥1 follow-up ≤30 days after discharge. Although the interventions were associated with lower rates of mortality and readmissions, which interventions are most clinically or cost-effective are unclear. How should high-sensitivity cardiac troponin I (hs-cTnI) levels be used to rule out myocardial infarction (MI) in the emergency department (ED)? High-STEACS Algorithm missed fewer patients with acute MI than the ESC Pathway in the ED Ann Intern Med. 2017;167:JC34. doi:10.7326/ACPJC-2017-167-6-034 This prospective cohort study evaluated 1218 patients who presented to the ED with suspected acute coronary syndrome who had hs-cTnI testing ordered by the attending clinician. The study compared the European Society of Cardiology (ESC) Pathway (which uses a 6-hour, sex-adjusted troponin cutoff) with the High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome (High-STEACS) Algorithm (which uses a 2-hour, unadjusted troponin cutoff). Both approaches use repeat troponin levels at 3 hours for early presenters. The High-STEACS Algorithm ruled out more MIs at presentation and demonstrated a higher negative predictive value at 3 hours than the ESC Pathway. 4 hs-cTnI algorithms had high sensitivity and low failure rates for ruling out acute MI in the ED Ann Intern Med. 2017;167:JC35. doi:10.7326/ACPJC-2017-167-6-035 This study used data from a prospective cohort of 2828 European patients who presented to the ED with suspected MI. It applied 4 strategies that used hs-cTnI to rule out MI and found that most strategies performed similarly. Taken together, the 2 aforementioned studies reflect growing interest in understanding how to most effectively use hs-cTnI to rule out MI in the ED. As important assumptions (e.g., that patient-reported symptom timing is accurate, and that all troponin assays are the same) and biases (e.g., incorporation bias and verification bias) within both studies limit conclusions, randomized trials focusing on this important question seem necessary. Sign up here to have Annals for Hospitalists delivered to your inbox each month.
Annals for Educators - 17 October 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Darren B. Taichman
Clinical Practice Points What You Can Do to Stop Firearm Violence The author calls upon physicians to educate themselves on how to identify patients at risk for harming themselves or others with firearms. He also asks that we make a personal commitment to ask our patients about firearms, counsel them on safe firearm behaviors, and take further action when an imminent hazard is present. Use this paper to: Ask your learners whether they think firearm-related injuries are a medical issue. Is it appropriate to approach the problem from an epidemiologic and public health perspective? Do your learners think they should talk to patients who they believe are at risk for firearm-related harm about how they can reduce the risks? Use the accompanying editorial to help frame your discussion. The author and editorialists encourage physicians to make a public commitment to talk to patients when they believe risks for firearm-related injuries are present. Do your learners think such declarations are useful or appropriate? Why or why not? Will your learners make such commitments? Will your learners talk to patients they believe are at risk? If so, do they know how? Do they know what they will ask and advise them? Use a recent paper that addresses such issues to help frame your discussion. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper Oregon's Death With Dignity Act: 20 Years of Experience to Inform the Debate The Slippery Slope of Legalization of Physician-Assisted Suicide Physician-Assisted Suicide: Finding a Path Forward in a Changing Legal Environment This series of articles includes a position paper from the American College of Physicians (ACP) on physician-assisted suicide. Another reviews 20 years of experience since Oregon's passage of the Death With Dignity Act, which allows physicians to prescribe medications to be self-administered by terminally ill patients to hasten their death. One of the editorials argues why the ACP position paper should be credited for its clarity and courage, whereas the other warns that the position paper misses an important opportunity to educate clinicians and learn about best practices. Use these papers to: Start a teaching session with a multiple-choice question. We've provided one below. Ask your learners if a patient has ever said that she or he would like to die. How have they responded? What questions should they ask? Have they ever been asked by a patient for help ending his or her life? Do they feel qualified to talk to patients about such issues? If not, what do they need to learn? Do your learners think there are situations where a patient's request for assistance in bringing about death should be honored? Why or why not? What are the laws regarding physician-assisted suicide where you practice? If it is legal, do your learners think all physicians have an obligation to participate? If not, how do we balance the needs and beliefs of the patients and physicians involved? Some health care professional societies oppose participation in physician-assisted suicide, whereas others provide support to physicians who do participate. What do your learners think is the best approach? Do your learners think there is a difference between palliative sedation and/or analgesics that, as a side effect, hasten death versus the provision of sedatives and/or analgesics that are used to bring about death? State Intimate Partner Violence–Related Firearm Laws and Intimate Partner Homicide Rates in the United States, 1991 to 2015 Intimate partner violence affects 1 in 3 women. This study examined the relationship between state intimate partner violence–related firearm laws and intimate partner homicides in the United States between 1991 and 2015. Use this study to: Ask your learners who is at risk for intimate partner violence. Do they ask patients whether they have been victims of intimate partner violence or are worried about this issue? Review the U.S. Preventive Services Task Force recommendation statement that recommends screening all women of childbearing age for intimate partner violence. Why have federal laws aimed at protecting women from intimate partner violence been less effective than they might have been? Do your learners think they will be comfortable asking their patients about these issues? Why or why not? How can they overcome any hesitation so as to better protect their patients? What else can physicians do to help reduce the risk for intimate partner violence? Use the accompanying editorial to help frame your discussion. Annals for Hospitalists Inpatient Notes: Diagnostic Excellence Starts With an Incessant Watch This concise paper discusses how we can improve our diagnostic skills by making better use of feedback on our performance. Use this paper to: Ask your learners whether they have received feedback on how well they have made correct diagnoses in their patients. How do we react when we learn that we have made an incorrect diagnosis or that it took longer than it should have to reach the right diagnosis? How can we improve how we make use of such feedback? Review the paper's table, and ask your learners if together you could adopt some of the suggested “tracking systems” the author proposes in your practices. How will you monitor yourself or each other to see whether this new approach is working? How will you judge success or failure? What does the author mean by “calibration” and “an incessant watch” with regard to improving one's diagnostic skills? Humanism and Professionalism On Being a Doctor: On Continuity Dr. Sinsky recalls how the continuity in her care for her patients, both in and out of the hospital, made enormous differences and meant the world to them (and her). Can such continuity survive as medical practice models evolve? Use this essay to: Listen to an audio recording of the essay, read by Dr. Michael LaCombe. How frequently do physicians at your center follow their outpatients when they are hospitalized? Do your learners go to see their outpatients when they are admitted? Why or why not? What are the barriers to outpatient-based physicians following their patients in the hospital? What pressures have made such practice less common? In what ways has hospital care been improved by its being led by physicians focusing only on inpatient care? What are the tradeoffs? The author wonders whether our profession will continue to develop systems where physicians work in the hospital or in outpatient settings, but not both. She believes that safer and more satisfying models will emerge but that they will be worked out by the next generation of physicians. What do your learners think is best? How should the system work? MKSAP 16 Question A 54-year-old man is evaluated for a long-standing history of COPD. Although he had previously done well, his lung function has progressively declined over the past year. He is oxygen dependent and is unable to perform even minor physical activity without severe dyspnea. He is not a transplant candidate and is unhappy with his quality of life and prognosis. He requests a prescription that he can take that will cause him to die at the time of his choosing. Which of the following is the most appropriate next step in management of this patient's request? A. Assess the adequacy of his current treatment B. Consult legal counsel about state law in such cases C. Decline the request D. Prescribe sedating medication that could ensure a comfortable death Correct Answer A. Assess the adequacy of his current treatment Educational Objective Manage a request for physician-assisted suicide. Critique When approached with a request for assistance in dying, it is best to respond to the request with empathy and compassion, and assess whether or not the patient is receiving adequate palliative interventions. Optimizing care interventions focused on maintaining or improving the quality of life may not always occur in the context of treating the underlying disease process; thus, reviewing the patient's overall care to address comfort and functional issues in severe illness is essential to appropriate management. Involving physicians trained specifically in palliative care medicine may also be helpful in such situations. Physician-assisted suicide is a controversial area of ethics. Most ethicists agree that it is acceptable to consider interventions that may hasten the death of a terminally ill patient if the primary intent is therapeutic (the principle of “double effect”). However, physician-assisted suicide using prescriptions or interventions with the specific intent to kill the patient is illegal in most states. The American Medical Association and the American College of Physicians have both taken positions against the practice. Seeking legal counsel may be advisable if one intends to provide the patient assistance in dying, as states in which it is legal have specific protocols that must be followed. However, this step would not be appropriate until alternatives such as improved palliative care were assessed. Categorically refusing to discuss a request for physician-assisted suicide can close the door to a discussion of why the patient is making the request and may jeopardize the therapeutic relationship with the patient. Writing a prescription for medication to assist a patient in dying without a detailed assessment of the patient's situation and motives would be irresponsible. Key Point When approached with a request for assistance in dying, it is best to respond to the request with empathy and compassion, and assess whether or not the patient is receiving adequate palliative care. Bibliography Snyder L, Sulmasy DP; Ethics and Human Rights Committee, American College of Physicians-American Society of Internal Medicine. Physician-assisted suicide. Ann Intern Med. 2001;135(3):209-216. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
- Acc. Chem. Res.
- ACS Appl. Mater. Interfaces
- ACS Biomater. Sci. Eng.
- ACS Catal.
- ACS Cent. Sci.
- ACS Chem. Biol.
- ACS Chem. Neurosci.
- ACS Comb. Sci.
- ACS Earth Space Chem.
- ACS Energy Lett.
- ACS Infect. Dis.
- ACS Macro Lett.
- ACS Med. Chem. Lett.
- ACS Nano
- ACS Omega
- ACS Photonics
- ACS Sens.
- ACS Sustainable Chem. Eng.
- ACS Synth. Biol.
- Acta Biomater.
- Acta Mater.
- Adv. Colloid Interface Sci.
- Adv. Electron. Mater.
- Adv. Energy Mater.
- Adv. Funct. Mater.
- Adv. Healthcare Mater.
- Adv. Mater.
- Adv. Mater. Interfaces
- Adv. Opt. Mater.
- Adv. Sci.
- Adv. Synth. Catal.
- AlChE J.
- Anal. Bioanal. Chem.
- Anal. Chem.
- Anal. Chim. Acta
- Anal. Methods
- Angew. Chem. Int. Ed.
- Annu. Rev. Anal. Chem.
- Annu. Rev. Biochem.
- Annu. Rev. Food Sci. Technol.
- Annu. Rev. Mater. Res.
- Annu. Rev. Phys. Chem.
- Appl. Catal. A Gen.
- Appl. Catal. B Environ.
- Appl. Clay. Sci.
- Appl. Energy
- Aquat. Toxicol.
- Arab. J. Chem.
- Asian J. Org. Chem.
- Atmos. Environ.
- Carbohydr. Polym.
- Catal. Commun.
- Catal. Sci. Technol.
- Catal. Today
- Cell Chem. Bio.
- Cem. Concr. Res.
- Ceram. Int.
- Chem. Asian J.
- Chem. Bio. Drug Des.
- Chem. Biol. Interact.
- Chem. Commun.
- Chem. Educ. Res. Pract.
- Chem. Eng. J.
- Chem. Eng. Sci.
- Chem. Eur. J.
- Chem. Mater.
- Chem. Phys.
- Chem. Phys. Lett.
- Chem. Phys. Lipids
- Chem. Rev.
- Chem. Sci.
- Chem. Soc. Rev.
- Combust. Flame
- Compos. Part A Appl. Sci. Manuf.
- Compos. Sci. Technol.
- Compr. Rev. Food Sci. Food Saf.
- Comput. Chem. Eng.
- Constr. Build. Mater.
- Coordin. Chem. Rev.
- Corros. Sci.
- Crit. Rev. Food Sci. Nutr.
- Crit. Rev. Solid State Mater. Sci.
- Cryst. Growth Des.
- Curr. Opin. Chem. Eng.
- Curr. Opin. Colloid Interface Sci.
- Curr. Opin. Environ. Sustain
- Curr. Opin. Solid State Mater. Sci.
- Ecotox. Environ. Safe.
- Electrochem. Commun.
- Electrochim. Acta
- Energy Environ. Sci.
- Energy Fuels
- Environ. Impact Assess. Rev.
- Environ. Int.
- Environ. Model. Softw.
- Environ. Pollut.
- Environ. Res.
- Environ. Sci. Policy
- Environ. Sci. Technol.
- Environ. Sci. Technol. Lett.
- Environ. Sci.: Nano
- Environ. Sci.: Processes Impacts
- Environ. Sci.: Water Res. Technol.
- Eur. J. Inorg. Chem.
- Eur. J. Med. Chem.
- Eur. J. Org. Chem.
- Eur. Polym. J.
- J. Acad. Nutr. Diet.
- J. Agric. Food Chem.
- J. Alloys Compd.
- J. Am. Ceram. Soc.
- J. Am. Chem. Soc.
- J. Am. Soc. Mass Spectrom.
- J. Anal. Appl. Pyrol.
- J. Anal. At. Spectrom.
- J. Antibiot.
- J. Catal.
- J. Chem. Educ.
- J. Chem. Eng. Data
- J. Chem. Inf. Model.
- J. Chem. Phys.
- J. Chem. Theory Comput.
- J. Chromatogr. A
- J. Chromatogr. B
- J. Clean. Prod.
- J. CO2 UTIL.
- J. Colloid Interface Sci.
- J. Comput. Chem.
- J. Cryst. Growth
- J. Dairy Sci.
- J. Electroanal. Chem.
- J. Electrochem. Soc.
- J. Environ. Manage.
- J. Eur. Ceram. Soc.
- J. Fluorine Chem.
- J. Food Drug Anal.
- J. Food Eng.
- J. Food Sci.
- J. Funct. Foods
- J. Hazard. Mater.
- J. Hydrol.
- J. Ind. Eng. Chem.
- J. Inorg. Biochem.
- J. Magn. Magn. Mater.
- J. Mater. Chem. A
- J. Mater. Chem. B
- J. Mater. Chem. C
- J. Mater. Process. Tech.
- J. Mech. Behav. Biomed. Mater.
- J. Med. Chem.
- J. Membr. Sci.
- J. Mol. Catal. A Chem.
- J. Mol. Liq.
- J. Nat. Gas Sci. Eng.
- J. Nat. Prod.
- J. Nucl. Mater.
- J. Org. Chem.
- J. Photochem. Photobiol. C Photochem. Rev.
- J. Phys. Chem. A
- J. Phys. Chem. B
- J. Phys. Chem. C
- J. Phys. Chem. Lett.
- J. Porphyr. Phthalocyanines
- J. Power Sources
- J. Solid State Chem.
- J. Taiwan Inst. Chem. E.
- Macromol. Rapid Commun.
- Mass Spectrom. Rev.
- Mater. Chem. Front.
- Mater. Des.
- Mater. Horiz.
- Mater. Lett.
- Mater. Sci. Eng. A
- Mater. Sci. Eng. R Rep.
- Mater. Today
- Meat Sci.
- Med. Chem. Commun.
- Microchem. J.
- Microchim. Acta
- Micropor. Mesopor. Mater.
- Mol. Biosyst.
- Mol. Cancer Ther.
- Mol. Catal.
- Mol. Nutr. Food Res.
- Mol. Pharmaceutics
- Mol. Syst. Des. Eng.
- Nano Energy
- Nano Lett.
- Nano Res.
- Nano Today
- Nano-Micro Lett.
- Nanoscale Horiz.
- Nat. Catal.
- Nat. Chem.
- Nat. Chem. Biol.
- Nat. Commun.
- Nat. Energy
- Nat. Mater.
- Nat. Med.
- Nat. Methods
- Nat. Nanotech.
- Nat. Photon.
- Nat. Prod. Rep.
- Nat. Protoc.
- Nat. Rev. Chem.
- Nat. Rev. Drug. Disc.
- Nat. Rev. Mater.
- Neurochem. Int.
- New J. Chem.
- NPG Asia Mater.
- npj 2D Mater. Appl.
- npj Comput. Mater.
- npj Flex. Electron.
- npj Mater. Degrad.
- npj Sci. Food
- Pharmacol. Rev.
- Pharmacol. Therapeut.
- Photochem. Photobiol. Sci.
- Phys. Chem. Chem. Phys.
- Phys. Life Rev.
- PLOS ONE
- Polym. Chem.
- Polym. Degrad. Stabil.
- Polym. J.
- Polym. Rev.
- Powder Technol.
- Proc. Combust. Inst.
- Prog. Cryst. Growth Ch. Mater.
- Prog. Energy Combust. Sci.
- Prog. Mater. Sci.
- Prog. Photovoltaics
- Prog. Polym. Sci.
- Prog. Solid State Chem.