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  • National Institutes of Health Pathways to Prevention Workshop: Achieving Health Equity in Preventive Services
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-14
    Timothy S. Carey; Betty Bekemeier; Doug Campos-Outcalt; Susan Koch-Weser; Sandra Millon-Underwood; Steven Teutsch

    Expert groups, including the U.S. Preventive Services Task Force (USPSTF), recommend a range of clinical preventive services for persons at average risk for disease. Use of these services often is substantially lower among racial and ethnic minority groups, rural residents, and persons of lower socioeconomic status. On 19 and 20 June 2019, the National Institutes of Health (NIH) convened the Pathways to Prevention Workshop: Achieving Health Equity in Preventive Services to assess the available evidence on disparities in the use of 10 USPSTF-recommended clinical preventive services for cancer, heart disease, and diabetes. The workshop was cosponsored by the NIH Office of Disease Prevention; National Institute on Minority Health and Health Disparities; National Cancer Institute; National Heart, Lung, and Blood Institute; and National Institute of Diabetes and Digestive and Kidney Diseases. A multidisciplinary working group developed the agenda, and an Evidence-based Practice Center prepared the evidence report. During the workshop, invited experts considered the evidence, with discussion among attendees. After weighing evidence from the review, presentations, and public comments, an independent panel prepared a draft report that was posted for public comment. This final report summarizes the panel's findings, identifying current gaps in knowledge. The panel made 26 recommendations for new research and methods development to improve implementation of proven services to reduce disparities in preventable conditions.

    更新日期:2020-01-14
  • Annals Graphic Medicine - Eewy Body Dementia
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-14
    Sharon Ostfeld-Johns

    更新日期:2020-01-14
  • Achieving Health Equity in Preventive Services: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-14
    Heidi D. Nelson; Amy Cantor; Jesse Wagner; Rebecca Jungbauer; Ana Quiñones; Lucy Stillman; Karli Kondo

    Background: Disadvantaged populations in the United States experience disparities in the use of preventive health services. Purpose: To examine effects of barriers that create health disparities in 10 recommended preventive services for adults, and to evaluate the effectiveness of interventions to reduce them. Data Sources: English-language searches of Ovid MEDLINE, PsycINFO, SocINDEX, and the Veterans Affairs Health Services database (1 January 1996 to 5 July 2019); reference lists. Study Selection: Trials, observational studies with comparison groups, and systematic reviews of populations adversely affected by disparities that reported effects of barriers on use of any of the 10 selected preventive services or that reported the effectiveness of interventions to reduce disparities in use of a preventive service by improving intermediate or clinical outcomes. Data Extraction: Dual extraction and assessment of study quality, strength of evidence, and evidence applicability. Data Synthesis: No studies reported effects of provider-specific barriers on preventive service use. Eighteen studies reporting effects of patient barriers, such as insurance coverage or lack of a regular provider, on preventive service use had mixed and inconclusive findings. Studies of patient–provider interventions (n = 12), health information technologies (n = 11), and health system interventions (n = 88) indicated higher cancer screening rates with patient navigation; telephone calls, prompts, and other outreach methods; reminders involving lay health workers; patient education; risk assessment, counseling, and decision aids; screening checklists; community engagement; and provider training. Single studies showed that clinician-delivered and technology-assisted interventions improved rates of smoking cessation and weight loss, respectively. Limitation: Insufficient or low strength of evidence and applicability for most interventions except patient navigation, telephone calls and prompts, and reminders involving lay health workers. Conclusion: In populations adversely affected by disparities, patient navigation, telephone calls and prompts, and reminders involving lay health workers increase cancer screening. Primary Funding Source: National Institutes of Health Office of Disease Prevention through an interagency agreement with the Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109263)

    更新日期:2020-01-14
  • Physician Time Spent Using the Electronic Health Record During Outpatient Encounters: A Descriptive Study
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-14
    J. Marc Overhage; David McCallie Jr.

    Background: The amount of time that providers spend using electronic health records (EHRs) to support the care delivery process is a concern for the U.S. health care system. Given the potential effect on patient care and the high costs related to this time, particularly for medical specialists whose work is largely cognitive, these findings warrant more precise documentation of the time physicians invest in these clinically focused EHR functions. Objective: To describe how much time ambulatory medical subspecialists and primary care physicians across several U.S. care delivery systems spend on various EHR functions. Design: Descriptive study. Setting: U.S.-based, adult, nonsurgical, ambulatory practices using the Cerner Millennium EHR. Participants: 155 000 U.S. physicians. Measurements: Data were extracted from software log files in the Lights On Network (Cerner) during 2018 that totaled the time spent on each of the 13 clinically focused EHR functions. Averages per encounter by specialty were computed. Results: This study included data from approximately 100 million patient encounters with about 155 000 physicians from 417 health systems. Physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33%), documentation (24%), and ordering (17%) functions accounting for most of the time. The distribution of time spent by providers using EHRs varies greatly within specialty. The proportion of time spent on various clinically focused functions was similar across specialties. Limitations: Variation by health system could not be examined, and all providers used the same software. Conclusion: The time spent using EHRs to support care delivery constitutes a large portion of the physicians' day, and wide variation suggests opportunities to optimize systems and processes. Primary Funding Source: None.

    更新日期:2020-01-14
  • Assessing the Risk for Gout With Sodium–Glucose Cotransporter-2 Inhibitors in Patients With Type 2 Diabetes: A Population-Based Cohort Study
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-14
    Michael Fralick; Sarah K. Chen; Elisabetta Patorno; Seoyoung C. Kim

    Background: Hyperuricemia is common in patients with type 2 diabetes mellitus and is known to cause gout. Sodium–glucose cotransporter-2 (SGLT2) inhibitors prevent glucose reabsorption and lower serum uric acid levels. Objective: To compare the rate of gout between adults prescribed an SGLT2 inhibitor and those prescribed a glucagon-like peptide-1 (GLP1) receptor agonist. Design: Population-based new-user cohort study. Setting: A U.S. nationwide commercial insurance database from March 2013 to December 2017. Patients: Persons with type 2 diabetes newly prescribed an SGLT2 inhibitor were 1:1 propensity score matched to patients newly prescribed a GLP1 agonist. Persons were excluded if they had a history of gout or had received gout-specific treatment previously. Measurements: The primary outcome was a new diagnosis of gout. Cox proportional hazards regression was used to estimate hazard ratios (HRs) of the primary outcome and 95% CIs. Results: The study identified 295 907 adults with type 2 diabetes mellitus who were newly prescribed an SGLT2 inhibitor or a GLP1 agonist. The gout incidence rate was lower among patients prescribed an SGLT2 inhibitor (4.9 events per 1000 person-years) than those prescribed a GLP1 agonist (7.8 events per 1000 person-years), with an HR of 0.64 (95% CI, 0.57 to 0.72) and a rate difference of −2.9 (CI, −3.6 to −2.1) per 1000 person-years. Limitation: Unmeasured confounding, missing data (namely incomplete laboratory data), and low baseline risk for gout. Conclusion: Adults with type 2 diabetes prescribed an SGLT2 inhibitor had a lower rate of gout than those prescribed a GLP1 agonist. Sodium–glucose cotransporter-2 inhibitors may reduce the risk for gout among adults with type 2 diabetes mellitus, although future studies are necessary to confirm this observation. Primary Funding Source: Brigham and Women's Hospital.

    更新日期:2020-01-14
  • Annals On Call - Approach to UGI Bleeding
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-07
    Robert M. Centor; Chad Burski

    In this episode of Annals On Call, Dr. Centor discusses the approach to patients with upper gastrointestinal bleeding with Dr. Chad Burski. Listen now. Annals articles discussed include... Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group: https://annals.org/aim/fullarticle/2753604/management-nonvariceal-upper-gastrointestinal-bleeding-guideline-recommendations-from-international-consensus About Annals On Call Annals On Call focuses on a clinically influential article published in Annals of Internal Medicine. Dr. Robert Centor shares his own perspective on the material and interviews topic area experts to discuss, debate, and share diverse insights about patient care and health care delivery. For more information on Annals On Call and for more episodes, visit go.annals.org/OnCall.

    更新日期:2020-01-08
  • Celiac Disease
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-07
    Joshua Elliott Rubin; Sheila E. Crowe

    Gluten-related disorders, including celiac disease, wheat allergy, and nonceliac gluten sensitivity (NCGS), are increasingly reported worldwide. Celiac disease is caused by an immune-mediated reaction to ingested gluten in genetically susceptible persons. NCGS is largely a diagnosis of exclusion when other causes of symptoms have been ruled out. All patients with celiac disease should be referred to a registered dietitian nutritionist with expertise in celiac disease and a gastroenterologist who specializes in celiac disease and malabsorptive disorders, and they should remain on a strict gluten-free diet indefinitely. This article provides an overview of gluten- and wheat-related disorders.

    更新日期:2020-01-08
  • Annals for Educators - 7 January 2020
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-07
    Darren B. Taichman

    Clinical Practice Points Compassionate End-of-Life Care: Mixed-Methods Multisite Evaluation of the 3 Wishes Project The 3 Wishes Project was pioneered in an academic medical center's intensive care unit (ICU) to promote compassionate end-of-life care by eliciting and fulfilling the wishes of dying patients or their families. This study evaluates the implementation and value of this project in various ICUs and medical centers. Use this study to: Ask your learners whether they ask dying patients or their families about their wishes and hopes. What sort of answers have they heard? Describe what the 3 Wishes Project entailed. Look at Table 1 to provide examples of the wishes involved in this study. Use the visual abstract to help explain the study to your learners. Watch the 7-minute author insight video with your team. Do your learners think an initiative to elicit and fulfill wishes like this one could be implemented at your center? Would they like to try? Does it have to be in the ICU only? Ask them how they could start. Is an organized project required, or could your learners try this one patient at a time? With whom could your learners speak to discuss implementing 3 Wishes at your center? What other team members should be involved in planning? Ask your learners to read the paper to be sure they know how much (or how little) was required in terms of commitment and investment by the centers involved in this study. An Emerging Crisis: Vaping-Associated Pulmonary Injury In the context of the emergence of vaping-associated pulmonary injury (VAPI), this commentary discusses what we know about the health effects of vaping and, more important, what we need to learn. Research on the respiratory toxicity of vaporized e-cigarette compounds and cannabis extracts, population studies on consumption patterns, and increased physician attention are urgently needed to mitigate the effects of VAPI. Use this paper to: Ask your learners if they know how VAPI is currently defined. In what settings should they consider VAPI in the differential diagnosis? What other causes of respiratory failure need to be considered? How should they be evaluated? Why would establishing a diagnosis of VAPI be useful if “supportive care” is all we currently have to offer? Do your learners talk to their patients about vaping? Should they? What should they discuss? Effectiveness and Cost-Effectiveness of Human Papillomavirus Vaccination Through Age 45 Years in the United States In the United States, the vaccine against human papillomavirus (HPV) is usually administered to girls and boys beginning just before the start of adolescence. Studies have shown that the vaccine prevents cancer and saves money when it is given this way. The U.S. Food and Drug Administration recently approved the vaccine for use in women and men up to age 45 years, and this article estimates the cost-effectiveness of the vaccine in these adults. Use this study to: Start a teaching session with a multiple-choice question. We've provided one below! For which patients is the HPV vaccine recommended? Look at the most recent recommendations from the Advisory Committee on Immunization Practices. Ask how cost-effectiveness analyses can be useful. How is “cost-effective” defined? What is the meaning of an incremental cost-effectiveness ratio (ICER) per quality-adjusted life-years gained? What ICER is often used as a benchmark for making health policy decisions? Invite an expert in cost-effectiveness studies or health policy to join your discussion. In the Clinic In the Clinic: Celiac Disease Gluten-related disorders, including celiac disease, wheat allergy, and nonceliac gluten sensitivity, are increasingly reported worldwide. Celiac disease is a multisystem disorder affecting approximately 0.7% of Americans and 1% of non-Hispanic white persons, many of whom have not been diagnosed. Unrecognized or untreated disease is associated with increased mortality and risk for intestinal lymphoma. Are your learners prepared? Use this feature to: Ask your learners what symptoms or signs should prompt consideration of celiac disease. See the boxes on pages 4 and 5. What are the potential gastrointestinal and extraintestinal manifestations? What autoimmune disorders are associated with celiac disease? What is dermatitis herpetiformis? Use Figure 1 to show your learners. Why might this physical finding be helpful? When should serum IgA and tissue transglutaminase testing be considered? What is the role of intestinal biopsy? What do your learners know about a gluten-free diet? How difficult is it to follow? Invite a nutritionist to join your discussion. Can a patient with celiac disease safely reintroduce gluten into his or her diet after initial control of their symptoms? Why or why not? Use the provided multiple-choice questions to help introduce topics in a teaching session. And, log on to enter your answers and earn CME/MOC credit for yourself. Humanism and Professionalism On Being a Doctor: Rise Up Dr. Collins implores us, “We must do better. These men deserve better.” Use this essay to: Listen to an audio recording, read by Dr. Virginia Hood. Ask your learners what the common causes of death from AIDS were in the 1990s. Invite a physician who cared for patients during that time to join your discussion. How commonly were patients with “end-stage” HIV infection admitted? What has changed? Why? What prevents some patients from receiving care for HIV infection? Does the social stigma of HIV infection continue to present a barrier to care? What can we as health care professionals do to combat it? MKSAP 18 Question A 22-year-old man returns for follow-up evaluation; he was recently diagnosed with HIV infection, and he began antiretroviral therapy 2 weeks ago. He also received influenza vaccination and the 13-valent pneumococcal conjugate vaccine at that time. He reports that he has sex with men. Medical history is notable for previous chlamydia infection and genital warts. Medications are tenofovir, emtricitabine, and dolutegravir. On physical examination, vital signs are normal. A few small lesions consistent with warts are noted on the penis. The examination is otherwise unremarkable. Laboratory studies: CD4 cell count  527/µL  Hepatitis A IgG  Positive  Hepatitis A IgM  Negative  Hepatitis B surface antibody  Negative  Hepatitis B surface antigen  Positive  CD4 cell count  527/µL  Hepatitis A IgG  Positive  Hepatitis A IgM  Negative  Hepatitis B surface antibody  Negative  Hepatitis B surface antigen  Positive  Which of the following is the most appropriate immunization to be given today? A. 23-Valent pneumococcal polysaccharide vaccine B. Hepatitis A vaccine C. Hepatitis B vaccine D. Human papillomavirus vaccine Correct Answer D. Human papillomavirus vaccine Educational Objective Provide appropriate immunizations for a patient with HIV infection. Critique Human papillomavirus (HPV) is the most appropriate immunization for this patient at this time. He was recently diagnosed with HIV infection and has begun antiretroviral therapy. At baseline, his CD4 cell count is normal. He is in an age group for which HPV immunization is recommended, and that recommendation is the same regardless of HIV status. The presence of genital warts does not change the indication for HPV vaccination. He should begin the HPV vaccine series with the first injection today. Indications for influenza, tetanus-diphtheria-pertussis, and hepatitis A virus (HAV) vaccines are also the same for patients with HIV infection as for the general population. Pneumococcal vaccination is important for all persons with HIV infection, regardless of CD4 cell count. As with other immunocompromised persons, patients with HIV should receive the 13-valent conjugate and 23-valent polysaccharide vaccines, in that order. This patient has already received the pneumococcal conjugate vaccine and needs the polysaccharide vaccine, but at least 8 weeks must elapse between these two vaccines to allow for better immune response in this prime-boost strategy. Therefore, giving him the pneumococcal polysaccharide vaccine at this visit would be premature. Serum IgM antibodies to HAV are detectable at the time of symptom onset and remain detectable for approximately 3 to 6 months. Serum IgG antibodies appear in convalescence and remain detectable for decades. The presence of anti-HAV IgG in the absence of anti-HAV IgM indicates past infection or vaccination. This patient does not need vaccination against HAV. Hepatitis B virus (HBV) surface antibody testing is negative, indicating a lack of immunity to HBV; he also has risk factors for HBV that would warrant HBV vaccination. However, the patient tested positive for hepatitis B surface antigen, indicating he already has HBV infection and would not benefit from immunization with the HBV vaccine. Key Point Indications for influenza, tetanus-diphtheria-pertussis, hepatitis A virus, and human papillomavirus vaccines are the same for patients with HIV infection as for the general population. Bibliography Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Accessed April 12, 2018. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.

    更新日期:2020-01-08
  • Health Care Administrative Costs in the United States and Canada, 2017
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-07
    David U. Himmelstein; Terry Campbell; Steffie Woolhandler

    Background: Before Canada's single-payer reform, its payment system, health costs, and number of health administrative personnel per capita resembled those of the United States. By 1999, administration accounted for 31% of U.S. health expenditures versus 16.7% in Canada. No recent comprehensive analyses of those costs are available. Objective: To quantify 2017 spending for administration by insurers and providers. Design: Analyses of government reports, accounting data that providers file with regulators, surveys of physicians, and census-collected data on employment in health care. Setting: United States and Canada. Measurements: Insurance overhead; administrative expenditures of hospitals, physicians, nursing homes, home care agencies, and hospices. Results: U.S. insurers and providers spent $812 billion on administration, amounting to $2497 per capita (34.2% of national health expenditures) versus $551 per capita (17.0%) in Canada: $844 versus $146 on insurers' overhead; $933 versus $196 for hospital administration; $255 versus $123 for nursing home, home care, and hospice administration; and $465 versus $87 for physicians' insurance-related costs. Of the 3.2–percentage point increase in administration's share of U.S. health expenditures since 1999, 2.4 percentage points was due to growth in private insurers' overhead, mostly because of high overhead in their Medicare and Medicaid managed-care plans. Limitations: Estimates exclude dentists, pharmacies, and some other providers; accounting categories for the 2 countries differ somewhat; and methodological changes probably resulted in an underestimate of administrative cost growth since 1999. Conclusion: The gap in health administrative spending between the United States and Canada is large and widening, and it apparently reflects the inefficiencies of the U.S. private insurance–based, multipayer system. The prices that U.S. medical providers charge incorporate a hidden surcharge to cover their costly administrative burden. Primary Funding Source: None.

    更新日期:2020-01-08
  • Testosterone Treatment in Adult Men With Age-Related Low Testosterone: A Clinical Guideline From the American College of Physicians
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-07
    Amir Qaseem; Carrie A. Horwitch; Sandeep Vijan; Itziar Etxeandia-Ikobaltzeta; Devan Kansagara

    Description: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations based on the current evidence of the benefits and harms of testosterone treatment in adult men with age-related low testosterone. This guideline is endorsed by the American Academy of Family Physicians. Methods: The ACP Clinical Guidelines Committee based these recommendations on a systematic review on the efficacy and safety of testosterone treatment in adult men with age-related low testosterone. Clinical outcomes were evaluated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system and included sexual function, physical function, quality of life, energy and vitality, depression, cognition, serious adverse events, major adverse cardiovascular events, and other adverse events. Target Audience and Patient Population: The target audience includes all clinicians, and the target patient population includes adult men with age-related low testosterone. Recommendation 1a: ACP suggests that clinicians discuss whether to initiate testosterone treatment in men with age-related low testosterone with sexual dysfunction who want to improve sexual function (conditional recommendation; low-certainty evidence). The discussion should include the potential benefits, harms, costs, and patient's preferences. Recommendation 1b: ACP suggests that clinicians should reevaluate symptoms within 12 months and periodically thereafter. Clinicians should discontinue testosterone treatment in men with age-related low testosterone with sexual dysfunction in whom there is no improvement in sexual function (conditional recommendation; low-certainty evidence). Recommendation 1c: ACP suggests that clinicians consider intramuscular rather than transdermal formulations when initiating testosterone treatment to improve sexual function in men with age-related low testosterone, as costs are considerably lower for the intramuscular formulation and clinical effectiveness and harms are similar. Recommendation 2: ACP suggests that clinicians not initiate testosterone treatment in men with age-related low testosterone to improve energy, vitality, physical function, or cognition (conditional recommendation; low-certainty evidence).

    更新日期:2020-01-08
  • Testosterone Treatment in Adult Men With Age-Related Low Testosterone
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-07

    What is age-related low testosterone? Testosterone is a male hormone. It plays a key role in male sexual and physical health. As men age, the amount of testosterone in their body slowly decreases. This condition is referred to as “age-related low testosterone.” When men have low testosterone, they may have symptoms, such as little or no interest in sex, erectile dysfunction, less energy/feeling weak, mood changes and feeling depressed, loss of bone mineral density, and loss of body and facial hair. It is not clear whether these symptoms are truly associated with low testosterone or if they are a result of other factors, such as chronic illness or certain medications. Who developed these recommendations? The American College of Physicians (ACP) developed these guidelines. The ACP is a professional organization for internal medicine doctors, who specialize in health care for adults. How did the ACP develop these guidelines? The ACP Clinical Guidelines Committee looked at the best available evidence on adult men with age-related low testosterone who received testosterone replacement therapy (TRT), as well as the outcomes of treatment, including patient values and preferences related to testosterone treatment. The guidelines do not address screening or diagnosing hypogonadism, or monitoring testosterone levels. What are the benefits and harms of TRT? Men with age-related low testosterone who receive TRT may show small improvement in sexual function and quality of life. However, evidence shows little or no benefits for common complaints of aging, such as less energy, vitality, physical function, and cognition. Harms from TRT, such as its effect on heart health, prostate cancer, or mortality, are difficult to judge because the available information is limited. In addition, the long-term benefits and harms of testosterone treatment are unknown, because most studies followed patients for only 12 months or less. What does the ACP recommend that patients and doctors do? Doctors and patients discuss whether to begin TRT in men with age-related low testosterone who want to improve sexual function. The discussion should include the potential benefits and harms of treatment, costs, and patient preferences. Doctors should reevaluate patients' symptoms within 12 months, and periodically thereafter. Testosterone replacement therapy should be stopped in men with age-related low testosterone with sexual dysfunction who do not see an improvement. Doctors should consider offering an intramuscular injection rather than transdermal formulations of testosterone (patches, creams, pellets) when beginning TRT to improve sexual function in men with age-related low testosterone. Costs are considerably lower for intramuscular injections, and the effectiveness and harms are similar to those of transdermal formulations. Questions for your doctor • Will taking TRT help with the symptoms that I came to discuss with you? • What method of TRT is best for me? • What are the risks and side effects of treatment? • How long will it take for TRT to work, and what if it does not work?

    更新日期:2020-01-07
  • Annals Graphic Medicine - More Than Suturing Wounds
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-07
    Annie Zhu; Arnav Agarwal

    更新日期:2020-01-07
  • 更新日期:2020-01-07
  • Efficacy and Safety of Testosterone Treatment in Men: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-07
    Susan J. Diem; Nancy L. Greer; Roderick MacDonald; Lauren G. McKenzie; Philipp Dahm; Nacide Ercan-Fang; Allison Estrada; Laura S. Hemmy; Christina E. Rosebush; Howard A. Fink; Timothy J. Wilt

    Background: Testosterone treatment rates in adult men have increased in the United States over the past 2 decades. Purpose: To assess the benefits and harms of testosterone treatment for men without underlying organic causes of hypogonadism. Data Sources: English-language searches of multiple electronic databases (January 1980 to May 2019) and reference lists from systematic reviews. Study Selection: 38 randomized controlled trials (RCTs) of at least 6 months' duration that evaluated transdermal or intramuscular testosterone therapies versus placebo or no treatment and reported prespecified patient-centered outcomes, as well as 20 long-term observational studies, U.S. Food and Drug Administration review data, and product labels that reported harms information. Data Extraction: Data extraction by a single investigator was confirmed by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. Data Synthesis: Studies enrolled mostly older men who varied in age, symptoms, and testosterone eligibility criteria. Testosterone therapy improved sexual functioning and quality of life in men with low testosterone levels, although effect sizes were small (low- to moderate-certainty evidence). Testosterone therapy had little to no effect on physical functioning, depressive symptoms, energy and vitality, or cognition. Harms evidence reported in trials was judged to be insufficient or of low certainty for most harm outcomes. No trials were powered to assess cardiovascular events or prostate cancer, and trials often excluded men at increased risk for these conditions. Observational studies were limited by confounding by indication and contraindication. Limitation: Few trials exceeded a 1-year duration, minimum important outcome differences were often not established or reported, RCTs were not powered to assess important harms, few data were available in men aged 18 to 50 years, definitions of low testosterone varied, and study entry criteria varied. Conclusion: In older men with low testosterone levels without well-established medical conditions known to cause hypogonadism, testosterone therapy may provide small improvements in sexual functioning and quality of life but little to no benefit for other common symptoms of aging. Long-term efficacy and safety are unknown. Primary Funding Source: American College of Physicians. (PROSPERO: CRD42018096585)

    更新日期:2020-01-07
  • Using High-Sensitivity Cardiac Troponin for the Exclusion of Inducible Myocardial Ischemia in Symptomatic Patients: A Cohort Study
    Ann. Intern. Med. (IF 19.315) Pub Date : 2020-01-07
    Joan Walter; Jeanne du Fay de Lavallaz; Luca Koechlin; Tobias Zimmermann; Jasper Boeddinghaus; Ursina Honegger; Ivo Strebel; Raphael Twerenbold; Melissa Amrein; Thomas Nestelberger; Desiree Wussler; Christian Puelacher; Patrick Badertscher; Michael Zellweger; Gregor Fahrni; Raban Jeger; Christoph Kaiser; Tobias Reichlin; Christian Mueller

    Background: The optimal noninvasive method for surveillance in symptomatic patients with stable coronary artery disease (CAD) is unknown. Objective: To apply a novel approach using very low concentrations of high-sensitivity cardiac troponin I (hs-cTnI) for exclusion of inducible myocardial ischemia in symptomatic patients with CAD. Design: Prospective diagnostic cohort study. (ClinicalTrials.gov: NCT01838148) Setting: University hospital. Patients: 1896 consecutive patients with CAD referred with symptoms possibly related to inducible myocardial ischemia. Measurements: Presence of inducible myocardial ischemia was adjudicated using myocardial perfusion imaging with single-photon emission computed tomography, as well as coronary angiography and fractional flow reserve measurements where available. Staff blinded to adjudication measured circulating hs-cTn concentrations. An hs-cTnI cutoff of 2.5 ng/L, derived previously in mostly asymptomatic patients with CAD, was assessed. Predefined target performance criteria were at least 90% negative predictive value (NPV) and at least 90% sensitivity for exclusion of inducible myocardial ischemia. Sensitivity analyses were based on measurements with an hs-cTnT assay and an alternative hs-cTnI assay with even higher analytic sensitivity (limit of detection, 0.1 ng/L). Results: Overall, 865 patients (46%) had inducible myocardial ischemia. The hs-cTnI cutoff of 2.5 ng/L provided an NPV of 70% (95% CI, 64% to 75%) and a sensitivity of 90% (CI, 88% to 92%) for exclusion of inducible myocardial ischemia. No hs-cTnI cutoff reached both performance characteristics predefined as targets. Similarly, using the alternative assays for hs-cTnI or hs-cTnT, no cutoff achieved the target performance: hs-cTnT concentrations less than 5 ng/L yielded an NPV of 66% (CI, 59% to 72%), and hs-cTnI concentrations less than 2 ng/L yielded an NPV of 68% (CI, 62% to 74%). Limitation: Data were generated in a large single-center diagnostic study using central adjudication. Conclusion: In symptomatic patients with CAD, very low hs-cTn concentrations, including hs-cTnI concentrations less than 2.5 ng/L, do not generally allow users to safely exclude inducible myocardial ischemia. Primary Funding Source: European Union, Swiss National Science Foundation, Kommission für Technologie und Innovation (Innosuisse), Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University of Basel, University Hospital Basel, Roche, Abbott, and Singulex.

    更新日期:2020-01-07
  • Disease-Modifying Effects of a Novel Cathepsin K Inhibitor in Osteoarthritis: A Randomized, Placebo-Controlled Study
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-31
    Philip G. Conaghan; Michael A. Bowes; Sarah R. Kingsbury; Alan Brett; Gwenael Guillard; Biljana Rizoska; Niclas Sjögren; Philippa Graham; Åsa Jansson; Cecilia Wadell; Richard Bethell; John Öhd

    Background: MIV-711 is a novel selective cathepsin K inhibitor with beneficial effects on bone and cartilage in preclinical osteoarthritis models. Objective: To evaluate the efficacy, safety, and tolerability of MIV-711 in participants with symptomatic, radiographic knee osteoarthritis. Design: 26-week randomized, double-blind, placebo-controlled phase 2a study with a 26-week open-label safety extension substudy. (EudraCT: 2015-003230-26 and 2016-001096-73) Setting: Six European sites. Participants: 244 participants with primary knee osteoarthritis, Kellgren–Lawrence grade 2 or 3, and pain score of 4 to 10 on a numerical rating scale (NRS). Intervention: MIV-711, 100 (n = 82) or 200 (n = 81) mg daily, or matched placebo (n = 77). Participants (46 who initially received 200 mg/d and 4 who received placebo) received 200 mg of MIV-711 daily during the extension substudy. Measurements: The primary outcome was change in NRS pain score. The key secondary outcome was change in bone area on magnetic resonance imaging (MRI). Other secondary end points included cartilage thickness on quantitative MRI and type I and II collagen C-telopeptide biomarkers. Outcomes were assessed over 26 weeks. Results: Changes in NRS pain scores with MIV-711 were not statistically significant (placebo, −1.4; MIV-711, 100 mg/d, −1.7; MIV-711, 200 mg/d, −1.5). MIV-711 significantly reduced medial femoral bone area progression (P = 0.002 for 100 mg/d and 0.004 for 200 mg/d) and medial femoral cartilage thinning (P = 0.023 for 100 mg/d and 0.125 for 200 mg/d) versus placebo and substantially reduced bone and cartilage biomarker levels. Nine serious adverse events occurred in 6 participants (1 in the placebo group, 3 in the 100 mg group, and 2 in the 200 mg group); none were considered to be treatment-related. Limitation: The trial was relatively short. Conclusion: MIV-711 was not more effective than placebo for pain, but it significantly reduced bone and cartilage progression with a reassuring safety profile. This treatment may merit further evaluation as a disease-modifying osteoarthritis drug. Primary Funding Source: Medivir.

    更新日期:2020-01-01
  • Correction: Nutritional Recommendations (NutriRECS) on Consumption of Red and Processed Meat
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-31

    On the author disclosure forms accompanying recent related articles on red and processed meat consumption and health outcomes (1–6), Bradley Johnston did not indicate a grant from Texas A&M AgriLife Research to fund investigator-driven research related to saturated and polyunsaturated fats. This funding is for work in the field of nutrition and the start of funding period was within the 36-month reporting period required in Section 3 of the disclosure form of the International Committee of Medical Journal Editors (ICMJE). Dr. Johnston has updated his disclosure form to include this research funding and also to note funding received from the International Life Science Institute (North America) that ended before the 36-month ICMJE reporting period. The corrected disclosure forms now accompany the articles (1–6). References Zeraatkar D, Han MA, Guyatt GH, et al Red and processed meat consumption and risk for all-cause mortality and cardiometabolic outcomes. A systematic review and meta-analysis of cohort studies. Ann Intern Med 2019 171 703 10 CrossRef Han MA, Zeraatkar D, Guyatt GH, et al Reduction of red and processed meat intake and cancer mortality and incidence. A systematic review and meta-analysis of cohort studies. Ann Intern Med 2019 171 711 20 CrossRef Zeraatkar D, Johnston BC, Bartoszko J, et al Effect of lower versus higher red meat intake on cardiometabolic and cancer outcomes. A systematic review of randomized trials. Ann Intern Med 2019 171 721 31 CrossRef Vernooij RWM, Zeraatkar D, Han MA, et al Patterns of red and processed meat consumption and risk for cardiometabolic and cancer outcomes. A systematic review and meta-analysis of cohort studies. Ann Intern Med 2019 171 732 41 CrossRef Valli BC, Rabassa M, Johnston BC, et al NutriRECS Working Grou Health-related values and preferences regarding meat consumption. A mixed-methods systematic review. Ann Intern Med 2019 171 742 55 CrossRef Johnston BC, Zeraatkar D, Han MA, et al Unprocessed red meat and processed meat consumption: dietary guideline recommendations from the Nutritional Recommendations (NutriRECS) Consortium. Ann Intern Med 2019 171 756 64 CrossRef

    更新日期:2019-12-31
  • Annals Graphic Medicine - Broken Speech
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-24
    Charlotte A. Wu; Kimberly R. Myers; Zoe S. Schein; Molly Osborne

    更新日期:2019-12-25
  • Preoperative N-Terminal Pro–B-Type Natriuretic Peptide and Cardiovascular Events After Noncardiac Surgery: A Cohort Study
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-24
    Emmanuelle Duceppe; Ameen Patel; Matthew T.V. Chan; Otavio Berwanger; Gareth Ackland; Peter A. Kavsak; Reitze Rodseth; Bruce Biccard; Clara K. Chow; Flavia K. Borges; Gordon Guyatt; Rupert Pearse; Daniel I. Sessler; Diane Heels-Ansdell; Andrea Kurz; Chew Yin Wang; Wojciech Szczeklik; Sadeesh Srinathan; Amit X. Garg; Shirley Pettit; Erin N. Sloan; James L. Januzzi; Matthew McQueen; Giovanna Lurati Buse; Nicholas L. Mills; Lin Zhang; Robert Sapsford; Guillaume Paré; Michael Walsh; Richard Whitlock; Andre Lamy; Stephen Hill; Lehana Thabane; Salim Yusuf; P.J. Devereaux

    Background: Preliminary data suggest that preoperative N-terminal pro–B-type natriuretic peptide (NT-proBNP) may improve risk prediction in patients undergoing noncardiac surgery. Objective: To determine whether preoperative NT-proBNP has additional predictive value beyond a clinical risk score for the composite of vascular death and myocardial injury after noncardiac surgery (MINS) within 30 days after surgery. Design: Prospective cohort study. Setting: 16 hospitals in 9 countries. Patients: 10 402 patients aged 45 years or older having inpatient noncardiac surgery. Measurements: All patients had NT-proBNP levels measured before surgery and troponin T levels measured daily for up to 3 days after surgery. Results: In multivariable analyses, compared with preoperative NT-proBNP values less than 100 pg/mL (the reference group), those of 100 to less than 200 pg/mL, 200 to less than 1500 pg/mL, and 1500 pg/mL or greater were associated with adjusted hazard ratios of 2.27 (95% CI, 1.90 to 2.70), 3.63 (CI, 3.13 to 4.21), and 5.82 (CI, 4.81 to 7.05) and corresponding incidences of the primary outcome of 12.3% (226 of 1843), 20.8% (542 of 2608), and 37.5% (223 of 595), respectively. Adding NT-proBNP thresholds to clinical stratification (that is, the Revised Cardiac Risk Index [RCRI]) resulted in a net absolute reclassification improvement of 258 per 1000 patients. Preoperative NT-proBNP values were also statistically significantly associated with 30-day all-cause mortality (less than 100 pg/mL [incidence, 0.3%], 100 to less than 200 pg/mL [incidence, 0.7%], 200 to less than 1500 pg/mL [incidence, 1.4%], and 1500 pg/mL or greater [incidence, 4.0%]). Limitation: External validation of the identified NT-proBNP thresholds in other cohorts would reinforce our findings. Conclusion: Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30 days after noncardiac surgery and improves cardiac risk prediction in addition to the RCRI. Primary Funding Source: Canadian Institutes of Health Research.

    更新日期:2019-12-25
  • 更新日期:2019-12-17
  • Annals On Call - Beware the Oxygen Fairy
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-17
    Robert M. Centor; Lisa H.Y. Kim

    In this episode of Annals On Call, Dr. Centor discusses the use of supplemental oxygen in hospitalized patients with Dr. Lisa Kim. Listen now. Annals articles discussed include... Annals for Hospitalists Inpatient Notes - Rethinking Oxygen Therapy for Hospitalized Patients: https://annals.org/aim/fullarticle/2751439/annals-hospitalists-inpatient-notes-rethinking-oxygen-therapy-hospitalized-patients About Annals On Call Annals On Call focuses on a clinically influential article published in Annals of Internal Medicine. Dr. Robert Centor shares his own perspective on the material and interviews topic area experts to discuss, debate, and share diverse insights about patient care and health care delivery. For more information on Annals On Call and for more episodes, visit go.annals.org/OnCall.

    更新日期:2019-12-17
  • Annals for Hospitalists - 17 December 2019
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-17
    David H. Wesorick; Vineet Chopra

    Inpatient Notes Clinical Pearls: E-cigarette, or Vaping, Product Use–Associated Lung Injury —Isaac Ghinai, MBBS, BSc, MSc, and Jennifer E. Layden, MD In recent months, more than 2000 cases of vaping-induced lung disease have been reported to the Centers for Disease Control and Prevention, including 39 deaths. In this article, investigators provide some clinical pearls about this emerging syndrome. Highlights of Recent Articles from Annals of Internal Medicine Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group Ann Intern Med. Published 22 October 2019. doi: 10.7326/M19-1795 This article is an update to the 2010 International Consensus Recommendations on the management of nonvariceal upper gastrointestinal bleeding (UGIB). It focuses on resuscitation and risk assessment; preendoscopic, endoscopic, and pharmacologic management; and secondary prophylaxis for recurrent nonvariceal UGIB. The updated recommendations were developed by an international multidisciplinary group of experts who reviewed the available evidence. Key points for hospitalists include: Preendoscopic management recommendations include the use of a transfusion threshold of 8 g/dL hemoglobin for most patients and a higher (but unspecified) threshold for patients with cardiovascular disease. Endoscopic management recommendations include endoscopy within 24 hours of presentation for patients with acute GIB (endoscopy and endoscopic therapy should not be delayed for patients receiving anticoagulation therapy). Patients with low-risk stigmata (clean-based ulcer) can be fed within 24 hours and discharged with a once-daily proton-pump inhibitor (PPI). Those with high-risk stigmata (active bleeding, visible vessel) should remain hospitalized and treated with a high-dose PPI intravenously for 72 hours (i.e., loading dose followed by continuous infusion). High-risk patients should then be treated with an oral PPI, twice daily, for 14 days before changing to once-daily dosing. Secondary prophylaxis with PPIs is recommended for all patients with a history of bleeding ulcers who require continued nonsteroidal anti-inflammatory therapy (switching to cyclooxygenase-2 inhibitors should be considered), dual antiplatelet therapy (DAPT), or anticoagulation. An editorialist notes that some questions of importance to hospitalists, such as the optimal resuscitation strategy for upper GIB patients and the optimal PPI regimen before endoscopy, remain unanswered. In the Clinic: Obstructive Sleep Apnea Ann Intern Med. 2019;171:ITC65-ITC80. This narrative review article provides an update on the screening, prevention, diagnosis, and treatment of obstructive sleep apnea (OSA). Key points for hospitalists include: Loud, bothersome snoring; apnea; and oxygen desaturation during sleep are sometimes observed in hospitalized patients. These findings should prompt consideration of OSA. Several randomized trials have demonstrated that home sleep apnea testing (HSAT), followed by the initiation of treatment in the home, leads to outcomes similar to those of sleep laboratory testing for patients with uncomplicated OSA. HSAT measures several respiratory variables (e.g., oximetry, airflow, chest movement), but does not include electroencephalography. This technology has allowed some patients to be diagnosed and treated by their primary care providers without the need for a formal laboratory sleep study. Untreated OSA in the perioperative setting is associated with higher rates of cardiopulmonary complications and intensive care unit transfers. In patients with both OSA and hypertension, continuous positive airway presser (or mandibular advancement devices) can lead to reduced blood pressure, and these reductions are especially great in patients with treatment-refractory hypertension. The Latest Highlights From Journal Club Does a bundled intervention, including corticosteroids and targeted nutritional therapy, improve length of stay or mortality in patients hospitalized with community-acquired pneumonia? In inpatients with community-acquired pneumonia, a bundled intervention with steroids did not reduce length of stay Ann Intern Med. 2019;171:JC52. doi: 10.7326/ACPJ201911190-052 This stepped-wedge cluster randomized controlled trial (RCT) compared patients receiving usual care to those receiving a bundled intervention (including prednisolone 50 mg/d for 7 days, early switch to oral antibiotics, early mobilization, and nutritional screening with targeted nutritional therapy). The 2 groups did not differ significantly for length of stay or mortality. After PCI and 3 months of DAPT, is P2Y12-inhibitor monotherapy inferior to continued DAPT? After PCI and 3 mo of DAPT, P2Y12-inhibitor monotherapy was noninferior to DAPT at 12 mo Ann Intern Med. 2019;171:JC53. doi:10.7326/ACPJ201911190-053 In this RCT, 2993 adults who received percutaneous cardiac intervention and completed 3 months of DAPT (with aspirin and a P2Y12 inhibitor) were randomly assigned to discontinue the aspirin or continue with both the aspirin and the P2Y12 inhibitor. Patients receiving P2Y12 inhibitor monotherapy did not experience any increase in major adverse cardiac events, all-cause death, stroke, or stent thrombosis at 12-month follow-up and had significantly less minor bleeding than patients who continued DAPT. Sign up here to have Annals for Hospitalists delivered to your inbox each month.

    更新日期:2019-12-17
  • Annals for Educators - 17 December 2019
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-17
    Darren B. Taichman

    We wish you, your patients, and your families a wonderful, healthy, and peaceful 2020! Clinical Practice Points Video Learning – Annals Consult Guys - Nausea and Vomiting After Surgery Geno and Howard, the Consult Gurus, take on how to approach the problem of nausea and emesis in patients after surgery. Use this feature to: Ask your learners what variables increase the risk for postoperative nausea and vomiting. How do your learners manage it? Do they consider prophylactic treatment? Now, watch the short video with your learners. Ask your learners whether they inquire about previous postoperative nausea and vomiting when evaluating a patient for planned surgery. Should they? Will it alter their management? What drugs are useful for the prevention of postoperative nausea and vomiting? What receptors do they target? Which patients should receive prophylaxis? How would your learners choose an agent to use? Log on and answer the multiple-choice question to earn CME/MOC credit! Altered Risk for Cardiovascular Events With Changes in the Metabolic Syndrome Status. A Nationwide Population-Based Study of Approximately 10 Million Persons Metabolic syndrome has become a growing public health problem worldwide. Much effort has been devoted to the prevention and treatment of this syndrome because affected persons have increased risk for cardiovascular disease. The objective of this population-based retrospective cohort study was to evaluate the risk for major adverse cardiovascular events among persons who develop or recover from metabolic syndrome. Use this study to: Ask your learners how metabolic syndrome is defined. Discuss why metabolic syndrome is important. Ask your learners whether they discuss the importance of metabolic syndrome with their patients. How do they explain the risks? What are their goals in such discussions? To motivate the patient? To scare the patient? Look at Figure 2 with your learners. How might these results be helpful in discussions with patients to motivate change? Suicide Case-Fatality Rates in the United States, 2007 to 2014. A Nationwide Population-Based Study The suicide case-fatality rate (CFR)—the proportion of suicidal acts that are fatal—depends on the distribution of methods used in the act and the probability of death given a particular method. In this cross-sectional study, the authors use data from 3 large databases from 2007 to 2014 to evaluate rates of suicide deaths and nonfatal suicide attempts, overall and method-specific CFRs, and distributions of methods used among persons aged 5 years or older. Use this study to: Ask your learners whether and when they ask patients about suicidal thoughts. What do they ask? Is the rate of suicidal acts higher for men or women? Are suicidal acts more commonly fatal in men or women? Why? Do your learners discuss the presence of firearms in their patients' homes? Should they? How should they do so? What should be discussed? Use the recent In the Clinic: Preventing Firearm-Related Death and Injury. Cases in Precision Medicine: The Role of Tumor and Germline Genetic Testing in Breast Cancer Management Genetic testing has improved the care of women with breast cancer, informing therapeutic and preventive management decisions. As a result of increasing availability and use of genetic testing, physicians frequently need to address patients' questions and concerns about the meaning of test results. The authors explain the importance of somatic and germline mutation analyses and their implications for patients and their families. Use this feature to: Start a teaching session with a multiple-choice question. We've provided one below! Read the presentation of the 47-year-old woman in the first paragraph to your learners. Then, ask your learners whether genetic testing would influence the care of this patient. Ask what the difference is between germline genetic testing and somatic testing of a tumor. How is each used? What counseling should occur before germline testing is performed? Invite a genetic counselor to join your discussion. MKSAP 18 Question A 26-year-old woman is interested in genetic testing for BRCA1 and BRCA2 gene mutations based on her family history. Her mother was diagnosed with triple-negative breast cancer at age 53 years and died at age 55 years. Her maternal aunt was diagnosed with ovarian cancer at age 48 years and is still alive but is not interested in genetic testing. Her maternal and paternal relatives are of Ashkenazi Jewish descent. The patient is premenopausal and takes no medications. On physical examination, vital signs are normal. Breast and gynecologic examination findings are normal. Which of the following is the most appropriate management? A. Recommend a direct-to-consumer genetic test B. Recommend against genetic testing C. Recommend genetic testing for the three BRCA1 and BRCA2 mutations most common in patients of Ashkenazi Jewish ethnicity D. Refer to a genetic counselor Correct Answer D. Refer to a genetic counselor Educational Objective Recommend genetic counseling to an asymptomatic patient with a family history of BRCA-related cancers. Critique The most appropriate management for this patient is referral to a genetic counselor. This patient has a family history suggestive of an inherited breast and ovarian cancer susceptibility gene and is interested in genetic testing. Both her mother and maternal aunt had cancers suggestive of a BRCA1 or BRCA2 mutation. Women with triple-negative breast cancers diagnosed before age 60 years are recommended to have BRCA1 and BRCA2 genetic testing, as are women with ovarian cancer diagnosed at any age. Referral to a genetic counselor or other suitably trained health care provider is the best option for genetic risk assessment. The U.S. Preventive Services Task Force has published guidelines for risk assessment and recommends referral to a genetic counselor for asymptomatic women who have not been diagnosed with a BRCA-related cancer but have a family history of BRCA-related cancers. These guidelines include screening tools designed to identify a family history that may be associated with an increased risk for BRCA1 or BRCA2 mutations. Family history factors suggesting an increased likelihood of BRCA mutations include breast cancer diagnosis before age 50 years, bilateral breast cancer, family history of breast and ovarian cancer, presence of breast cancer in one or more male family members, multiple cases of breast cancer in the family, one or more family member with two primary types of BRCA-related cancer, and Ashkenazi Jewish ethnicity. Genetic counseling should always occur before any genetic test is performed. The essential components of counseling include informing the patient of the test purpose, implications of diagnosis, alternative testing options (including foregoing testing), and any possible risks and benefits. The National Society of Genetic Counselors Web site can be used to locate a genetic counselor. Direct-to-consumer tests may not include the appropriate type of genetic testing. In addition, genetic testing should be done after pretest genetic counseling, which is not always available in patients being tested by direct-to-consumer commercial genetic tests. Although BRCA1 and BRCA2 testing for the three mutations most common in the Ashkenazi Jewish population (called multisite testing) is recommended for Ashkenazi Jewish women with breast cancer diagnosed at any age, comprehensive BRCA1 and BRCA2 testing is recommended if additional criteria for BRCA1/2 testing are met. Key Point Asymptomatic patients with a family history of BRCA-related cancers should receive genetic counseling for genetic risk assessment. Bibliography Moyer VA; U.S. Preventive Services Task Force. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:271-81. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.

    更新日期:2019-12-17
  • Annals Consult Guys - Nausea and Vomiting After Surgery
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-17
    Geno J. Merli; Howard H. Weitz

    Annals Consult Guys brings a new perspective to the art and science of medicine with lively discussion and analysis of real-world cases and situations. They address medically relevant topics—whether they be poignant, thought-provoking, or just plain entertaining. For more videos from and information on Annals Consult Guys, visit go.annals.org/ConsultGuys.

    更新日期:2019-12-17
  • Correction: Effects of Nutritional Supplements and Dietary Interventions on Cardiovascular Outcomes
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-17

    We (1) adopted an a priori model consistent with a general recommendation for the use of Hartung–Knapp–Sidik–Jonkman (HKSJ) adjustment with the Paule–Mandel (PM) estimator of between-study variance (τ2) when the number of trials (k) was 10 or fewer (2, 3). However, Kivelä, Mayer, and Cornell and Mulrow highlighted that using standard HKSJ adjustment with the PM method can underestimate the uncertainty when k < 5 and τ2 = 0, and in our article led to narrower CIs in evaluating the effect of reduced salt intake on all-cause mortality in normotensive patients (1–3). Considering the difficulty in generating robust estimates in such a scenario, Kivelä, Mayer, and Cornell and Mulrow encouraged us to conduct additional analyses using modified HKSJ, Bayesian, or profile likelihood methods where relevant (2). Accordingly, we performed sensitivity analyses for all interventions and outcomes, where k > = 2 but < 5 and τ2 = 0 using modified HKSJ with the PM method. Statistical analyses were conducted using “meta” commands from Stata, version 16. Consistent with the already-published statistical plan (1), statistical significance was set at 0.05 and effect sizes were reported as risk ratios (RRs) with 95% CIs. We used I2 statistics to estimate the extent of unexplained heterogeneity; I2 greater than 50% was considered a high degree of between-study heterogeneity. Twenty-nine estimates were reanalyzed. As expected, CIs widened with adjustment. Two estimates changed from protective to nonsignificant: 1) low-salt diet on all-cause mortality (RR, 0.90 [95% CI, 0.34–2.36]; low certainty of evidence) in hypertensive patients and 2) cardiovascular mortality (RR, 0.67 [CI, 0.28–1.64]; low certainty of evidence) in normotensive patients. There was no important change in conclusions or certainty in evidence for the other 27 estimates (Table). Table. Sensitivity Analyses and Implications on Outcomes* Table. Sensitivity Analyses and Implications on Outcomes* These sensitivity analyses further validate the lack of cardiovascular effects of various nutritional supplements and dietary interventions. The editorialists highlighted the controversial finding of better mortality outcomes with a low-salt diet in view of limited evidence (4). We also discussed the inconsistent data supporting the cardiovascular benefits of a low-salt diet (1). Therefore, in view of these sensitivity analyses, the certainty of evidence regarding cardiovascular effects of reduced salt intake should be downgraded. Essentially, our updated findings support the 2019 National Academies consensus study regarding insufficient evidence to establish estimates average requirement or recommended dietary allowance for sodium (5). Meta-analyses with a small number of included studies remain a challenge. It is a difficult decision to choose between the a priori selected model and a new post hoc data-driven model. In this case, the new model likely yields the more conservative and appropriate results. References Khan SU, Khan MU, Riaz H, et al. Effects of nutritional supplements and dietary interventions on cardiovascular outcomes: an umbrella review and evidence map. Ann Intern Med. 2019;171:190-8. [PMID: 31284304] doi:10.7326/M19-0341 Veroniki AA, Jackson D, Bender R, et al. Methods to calculate uncertainty in the estimated overall effect size from a random-effects meta-analysis. Res Synth Methods. 2019;10:23-43. [PMID: 30129707] doi:10.1002/jrsm.1319 Knapp G, Hartung J. Improved tests for a random effects meta-regression with a single covariate. Stat Med. 2003;22:2693-710. [PMID: 12939780] Pandey AC, Topol EJ. Dispense with supplements for improving heart outcomes. Ann Intern Med. 2019;171:216-7. [PMID: 31284306] doi:10.7326/M19-1498 National Academies of Sciences, Engineering, and Medicine. Dietary Reference Intakes for Sodium and Potassium. Washington, DC: National Academies Pr; 2019.

    更新日期:2019-12-17
  • Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-17
    David M. Levine; Kei Ouchi; Bonnie Blanchfield; Agustina Saenz; Kimberly Burke; Mary Paz; Keren Diamond; Charles T. Pu; Jeffrey L. Schnipper

    Background: Substitutive hospital-level care in a patient's home may reduce cost, health care use, and readmissions while improving patient experience, although evidence from randomized controlled trials in the United States is lacking. Objective: To compare outcomes of home hospital versus usual hospital care for patients requiring admission. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT03203759) Setting: Academic medical center and community hospital. Patients: 91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions. Intervention: Acute care at home, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing. Measurements: The primary outcome was the total direct cost of the acute care episode (sum of costs for nonphysician labor, supplies, medications, and diagnostic tests). Secondary outcomes included health care use and physical activity during the acute care episode and at 30 days. Results: The adjusted mean cost of the acute care episode was 38% (95% CI, 24% to 49%) lower for home patients than control patients. Compared with usual care patients, home patients had fewer laboratory orders (median per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), and consultations (median, 2% vs. 31%). Home patients spent a smaller proportion of the day sedentary (median, 12% vs. 23%) or lying down (median, 18% vs. 55%) and were readmitted less frequently within 30 days (7% vs. 23%). Limitation: The study involved 2 sites, a small number of home physicians, and a small sample of highly selected patients (with a 63% refusal rate among potentially eligible patients); these factors may limit generalizability. Conclusion: Substitutive home hospitalization reduced cost, health care use, and readmissions while increasing physical activity compared with usual hospital care. Primary Funding Source: Partners HealthCare Center for Population Health and internal departmental funds.

    更新日期:2019-12-17
  • Effectiveness and Cost-Effectiveness of Human Papillomavirus Vaccination Through Age 45 Years in the United States
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-10
    Jean-François Laprise, Harrell W. Chesson, Lauri E. Markowitz, Mélanie Drolet, Dave Martin, Élodie Bénard, Marc Brisson

    Background: In the United States, the routine age for human papillomavirus (HPV) vaccination is 11 to 12 years, with catch-up vaccination through age 26 years for women and 21 years for men. U.S. vaccination policy on use of the 9-valent HPV vaccine in adult women and men is being reviewed. Objective: To evaluate the added population-level effectiveness and cost-effectiveness of extending the current U.S. HPV vaccination program to women aged 27 to 45 years and men aged 22 to 45 years. Design: The analysis used HPV-ADVISE (Agent-based Dynamic model for VaccInation and Screening Evaluation), an individual-based transmission dynamic model of HPV infection and associated diseases, calibrated to age-specific U.S. data. Data Sources: Published data. Target Population: Women aged 27 to 45 years and men aged 22 to 45 years in the United States. Time Horizon: 100 years. Perspective: Health care sector. Intervention: 9-valent HPV vaccination. Outcome Measures: HPV-associated outcomes prevented and cost-effectiveness ratios. Results of Base-Case Analysis: The model predicts that the current U.S. HPV vaccination program will reduce the number of diagnoses of anogenital warts and cervical intraepithelial neoplasia of grade 2 or 3 and cases of cervical cancer and noncervical HPV-associated cancer by 82%, 80%, 59%, and 39%, respectively, over 100 years and is cost saving (vs. no vaccination). In contrast, extending vaccination to women and men aged 45 years is predicted to reduce these outcomes by an additional 0.4, 0.4, 0.2, and 0.2 percentage points, respectively. Vaccinating women and men up to age 30, 40, and 45 years is predicted to cost $830 000, $1 843 000, and $1 471 000, respectively, per quality-adjusted life-year gained (vs. current vaccination). Results of Sensitivity Analysis: Results were most sensitive to assumptions about natural immunity and progression rates after infection, historical vaccination coverage, and vaccine efficacy. Limitation: Uncertainty about the proportion of HPV-associated disease due to infections after age 26 years and about the level of herd effects from the current HPV vaccination program. Conclusion: The current HPV vaccination program is predicted to be cost saving. Extending vaccination to older ages is predicted to produce small additional health benefits and result in substantially higher incremental cost-effectiveness ratios than the current recommendation. Primary Funding Source: Centers for Disease Control and Prevention.

    更新日期:2019-12-11
  • Annals Graphic Medicine - Crime and Punishment
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-10
    Stefan Tigges

    更新日期:2019-12-11
  • Predicting 6-Month Mortality for Older Adults Hospitalized With Acute Myocardial Infarction: A Cohort Study
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-10
    John A. Dodson, Alexandra M. Hajduk, Mary Geda, Harlan M. Krumholz, Terrence E. Murphy, Sui Tsang, Mary E. Tinetti, Michael G. Nanna, Richard McNamara, Thomas M. Gill, Sarwat I. Chaudhry

    Background: Older adults with acute myocardial infarction (AMI) have higher prevalence of functional impairments, including deficits in cognition, strength, and sensory domains, than their younger counterparts. Objective: To develop and evaluate the prognostic utility of a risk model for 6-month post-AMI mortality in older adults that incorporates information about functional impairments. Design: Prospective cohort study. (ClinicalTrials.gov: NCT01755052). Setting: 94 hospitals throughout the United States. Participants: 3006 persons aged 75 years or older who were hospitalized with AMI and discharged alive. Measurements: Functional impairments were assessed during hospitalization via direct measurement (cognition, mobility, muscle strength) or self-report (vision, hearing). Clinical variables associated with mortality in prior risk models were ascertained by chart review. Seventy-two candidate variables were selected for inclusion, and backward selection and Bayesian model averaging were used to derive (n = 2004 participants) and validate (n = 1002 participants) a model for 6-month mortality. Results: Participants' mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. There were 266 deaths (8.8%) within 6 months. The final risk model included 15 variables, 4 of which were not included in prior risk models: hearing impairment, mobility impairment, weight loss, and lower patient-reported health status. The model was well calibrated (Hosmer–Lemeshow P > 0.05) and showed good discrimination (area under the curve for the validation cohort = 0.84). Adding functional impairments significantly improved model performance, as evidenced by category-free net reclassification improvement indices of 0.21 (P = 0.008) for hearing impairment and 0.26 (P < 0.001) for mobility impairment. Limitation: The model was not externally validated. Conclusion: A newly developed model for 6-month post-AMI mortality in older adults was well calibrated and had good discriminatory ability. This model may be useful in decision making at hospital discharge. Primary Funding Source: National Heart, Lung, and Blood Institute of the National Institutes of Health.

    更新日期:2019-12-11
  • Annals Graphic Medicine - Dr. Mom: How Do You ...?
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-03
    Grace E. Farris

    更新日期:2019-12-04
  • Obstructive Sleep Apnea
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-03
    Sanjay R. Patel

    Obstructive sleep apnea (OSA) is very common but is frequently undiagnosed. Symptoms include loud snoring, nocturnal awakening, and daytime sleepiness. Motor vehicle accidents due to drowsy driving are a particular concern. Evaluation and treatment should focus on symptomatic patients, both to alleviate symptoms and to potentially decrease cardiovascular risk. In recent years, a strategy of home sleep apnea testing followed by initiation of autotitrating continuous positive airway pressure therapy in the home has greatly reduced barriers to diagnosis and treatment and has also facilitated routine management of OSA by primary care providers.

    更新日期:2019-12-04
  • Suicide Case-Fatality Rates in the United States, 2007 to 2014: A Nationwide Population-Based Study
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-03
    Andrew Conner, Deborah Azrael, Matthew Miller

    Background: The suicide case-fatality rate (CFR)—the proportion of suicidal acts that are fatal—depends on the distribution of methods used in suicidal acts and the probability of death given a particular method (method-specific CFR). Objective: To estimate overall and method-specific suicide CFRs and the distribution of methods used in suicidal acts by demographic characteristics. Design: Cross-sectional study. Setting: United States, 2007 to 2014. Participants: Suicide deaths (n = 309 377 records from the National Vital Statistics System) and nonfatal suicide attempts requiring treatment in an emergency department (ED) (n = 1 791 638 records from the Nationwide Emergency Department Sample) or hospitalization (n = 1 556 871 records from the National [Nationwide] Inpatient Sample) among persons aged 5 years or older. Measurements: Rates of suicide deaths and nonfatal suicide attempts, overall and method-specific CFRs, and distribution of methods used, by sex, age group, region, and urbanization. Results: Overall, 8.5% of suicidal acts were fatal (14.7% for males vs. 3.3% for females; 3.4% for persons aged 15 to 24 years vs. 35.4% for those aged ≥65 years). Drug poisoning accounted for 59.4% of acts but only 13.5% of deaths; firearms and hanging accounted for only 8.8% of acts but 75.3% of deaths. Firearms were the most lethal method (89.6% of suicidal acts with a firearm resulted in death), followed by drowning (56.4%) and hanging (52.7%). Method-specific CFRs were higher for males and older persons. The distribution of methods varied across demographic groups. Limitations: Results are based on suicidal acts resulting in an ED visit, a hospitalization, or death. Consequently, the reported CFRs are larger than they would have been had the data included nonfatal attempts that did not result in an ED visit. Conclusion: Variation in overall suicide CFR between sexes and across age groups, regions, and urbanization is largely explained by the distribution of methods used in suicidal acts. Primary Funding Source: Joyce Foundation.

    更新日期:2019-12-04
  • Annals On Call - Technology to Improve Diabetes Management
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-03
    Robert M. Centor, Fernando Ovalle

    In this episode of Annals On Call, Dr. Centor discusses the use of technology to improve diabetes management with Dr. Fernando Ovalle of the University of Alabama at Birmingham. Listen now. Annals articles discussed include... Diabetes Technology: Review of the 2019 American Diabetes Association Standards of Medical Care in Diabetes: https://annals.org/aim/fullarticle/2748278/diabetes-technology-review-2019-american-diabetes-association-standards-medical-care About Annals On Call Annals On Call focuses on a clinically influential article published in Annals of Internal Medicine. Dr. Robert Centor shares his own perspective on the material and interviews topic area experts to discuss, debate, and share diverse insights about patient care and health care delivery. For more information on Annals On Call and for more episodes, visit go.annals.org/OnCall.

    更新日期:2019-12-03
  • Annals for Educators - 3 December 2019
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-03
    Darren B. Taichman

    Clinical Practice Points Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group This guideline updates the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB). Use this paper to: Start a teaching session with a multiple-choice question. We've provided one below! What are the immediate considerations for evaluation and management of patients with potential UGIB? Ask your learners what the risk factors are for UGIB. Do all patients with UGIB require hospitalization? How do your learners decide? Review the variables of the Glasgow Blatchford score. What score is recommended to identify a sufficiently low risk for rebleeding to consider outpatient management? Is this in line with practice at your hospital? Do your learners think it should be? Which patients require blood transfusion? Note the difference in thresholds for transfusion recommended in the multiple-choice question below and in the guideline. Why might recommendations differ? What do your learners plan to do? How should proton-pump inhibitors be administered, and for how long? How does a patient's need for anticoagulant or antiplatelet therapy influence the approach to proton-pump inhibitor therapy? Cases in Precision Medicine: A Personalized Approach to Stroke and Cardiovascular Risk Assessment in Women Cardiovascular disease is the leading cause of death among women in the United States, and stroke is third. This article discusses female-specific cardiovascular risk factors across the lifespan and describes a precision medicine–based approach to risk factor modification and primary prevention, including the current role of genetic testing in the assessment of risk for cardiovascular disease and stroke. Use this paper to: Read the presentation of a 46-year-old woman seeking advice about her risk for cardiovascular disease with your learners. Ask your learners how they would answer this patient's question regarding a “test” to assess whether “stroke is in her genes.” How would your learners assess this patient's risk? Is there a role for genetic testing? How does this patient's history of migraine influence your learners' assessment of her risk? What other variables influence her risk? Use the Figure. Beyond the Guidelines Should This Patient Be Screened for Atrial Fibrillation? Grand Rounds Discussion From Beth Israel Deaconess Medical Center Two cardiologists discuss the U.S. Preventive Services Task Force guidelines on atrial fibrillation and whether they would recommend anticoagulation for a specific patient with screen-detected atrial fibrillation. Use this feature to: Watch the video interview of Dr. V, a 69-year-old woman with an asymptomatic episode of tachycardia noted during ambulatory blood pressure monitoring. Ask your learners whether they would recommend screening patients for atrial fibrillation. Why or why not? What are the potential benefits and harms? Review the background material and the arguments made by the 2 discussants. Alternatively, watch the video of the grand rounds presentation. Have your learners changed their minds about screening? In the Clinic In the Clinic: Obstructive Sleep Apnea Obstructive sleep apnea (OSA) is very common but is frequently undiagnosed. It occurs in 14% of men and 5% of women in the general adult population. Yet, only 1 in 50 patients with suggestive symptoms is evaluated and treated. Do your learners know when to consider OSA and how to evaluate for its possible presence? Use this review to: Ask your learners what conditions increase the risk for OSA. See the Box: Risk Factors for Obstructive Sleep Apnea. Should we screen for OSA? If so, in whom? How would your learners do so? Are they familiar with the STOP-BANG approach? What evaluation should occur if OSA is suspected? Are in-laboratory sleep studies required for diagnosis or treatment? How is treatment initiated? Is evaluation by a specialist always required? Use the provided multiple-choice questions to introduce topics during a teaching session. Be sure to log in and enter your answer to claim CME and MOC credit. Humanism and Professionalism A Veteran-Centric Model of Care: Crossing the Cultural Divide Although most U.S. physicians train at Veterans Health Administration hospitals, few have served in the military. The author, a veteran and physician, discusses how failure to appreciate the differences between the civilian and military cultures can result in misalignment of veterans' and physicians' perspectives during management of a veteran's health. Use this essay to: Ask your learners whether they have noted differences in their interactions with patients who are veterans compared with those who have not served in the military. Do your learners ask patients who are veterans about their service history? Should they? When? What questions should be asked? Use the Table. Why might these questions be helpful? Have your learners encountered the kinds of misunderstanding or miscommunication described by the author? On Being a Doctor: The Liver Transplant Unit The reality that her partner's liver will fail plunges Dr. Adler into a different side of doctoring. Use this essay to: Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners whether they are ever jarred by thoughts of a loved one when they see a patient with an illness. Is it different to face a loved one's illness as a physician? Do our knowledge of medicine and our experiences with advanced disease make things better or worse? MKSAP 18 Question A 55-year-old man is evaluated after being hospitalized for epigastric pain of 1 month's duration and melenic stools over the past 3 days associated with fatigue. He reports no hematochezia, hematemesis, chest pain, or shortness of breath. He has osteoarthritis treated with ibuprofen. He received an intravenous fluid bolus in the emergency department. On physical examination, blood pressure is 135/75 mm Hg and other vital signs are normal, with no orthostatic changes. Abdominal examination reveals epigastric tenderness but is otherwise unremarkable. No stigmata of chronic liver disease are seen. Laboratory studies show a hemoglobin level of 7.3 g/dL (73 g/L). Upper endoscopy shows a 1.5-cm duodenal bulb ulcer with a clean base. Which of the following is the most appropriate resuscitation measure? A. Transfuse red blood cells to a goal hemoglobin level of 8 g/dL (80 g/L) B. Transfuse red blood cells to a goal hemoglobin level of 9 g/dL (90 g/L) C. Transfuse red blood cells to a goal hemoglobin level of 10 g/dL (100 g/L) D. No transfusion Correct Answer D. No transfusion Educational Objective Treat upper gastrointestinal bleeding. Critique This patient does not require transfusion. For patients with upper gastrointestinal bleeding, initial resuscitation is the first priority and should include stabilization of blood pressure with infusion of sufficient volumes of crystalloid fluid and/or red blood cells. The decision to transfuse red blood cells is based mainly on the presenting hemoglobin level. In hemodynamically stable patients, a restrictive transfusion strategy (transfusion threshold of less than 7 g/dL [70 g/L] with a target hemoglobin level of 7-9 g/dL [70-90 g/L]) is associated with decreased mortality, length of hospital stay, and transfusion-related adverse events compared to a liberal transfusion strategy (transfusion threshold of less than 9 g/dL [90 g/L] with a target hemoglobin level of 9-10 g/dL [90-100 g/L]). This patient is hemodynamically and physiologically stable with no evidence of ongoing overt gastrointestinal blood loss or symptoms of tissue ischemia; therefore, it is appropriate to continue maintenance intravenous fluids because he is at an appropriate target hemoglobin level of 7 to 9 g/dL (70-90 g/L). A modification of the restrictive transfusion threshold may be considered in specific subpopulations, such as patients with hypotension due to severe bleeding and patients with cardiovascular disease. It may be reasonable to give transfusions to patients who are hemodynamically unstable before a decline in hemoglobin level to less than 7 g/dL (70 g/L) to prevent complications of tissue underperfusion. There is uncertainty regarding the need for a higher transfusion threshold in patients with cardiovascular disease, but current guidelines recommend considering transfusion when hemoglobin levels decrease below 8 g/dL (80 g/L) or when cardiovascular symptoms develop (for example, chest pain, dyspnea) in patients who are otherwise hemodynamically stable. Key Point In patients with upper gastrointestinal bleeding, a restrictive transfusion strategy (transfusion threshold of less than 7 g/dL [70 g/L] with a target hemoglobin level of 7-9 g/dL [70-90 g/L]) is associated with decreased mortality, length of hospital stay, and transfusion-related adverse events compared to a liberal transfusion strategy. Bibliography Fortinsky KJ, Bardou M, Barkun AN. Role of medical therapy for nonvariceal upper gastrointestinal bleeding. Gastrointest Endosc Clin N Am. 2015;25:463-78. doi:10.1016/j.giec.2015.02.003 Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.

    更新日期:2019-12-03
  • Should This Patient Be Screened for Atrial Fibrillation?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-03
    Risa B. Burns, Peter Zimetbaum, Steven A. Lubitz, Gerald W. Smetana

    Atrial fibrillation (AFib) is the most common type of cardiac arrhythmia, affecting 2.7 million to 6.1 million persons in the United States. Although some persons with AFib have no symptoms, others do. For those without symptoms, AFib may be detected by 12-lead electrocardiogram (ECG), single-lead monitors (such as ambulatory blood pressure monitors and pulse oximeters), or consumer devices (such as wearable monitors and smartphones). Pulse palpation and heart auscultation also may detect AFib. In a systematic review, screening with ECG identified more new cases of AFib than no screening. Atrial fibrillation is an important cause of stroke, and without anticoagulant treatment, patients with AFib have approximately a 5-fold increased risk for stroke. The U.S. Preventive Services Task Force reviewed the benefits and harms of ECG screening for AFib in adults aged 65 years or older and found inadequate evidence that ECG identifies AFib more effectively than usual care. This conclusion is in contrast to guidelines from the European Society of Cardiology and the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand, which found that active screening for AFib in patients older than 65 years may be useful. Here, 2 cardiologists discuss the risks and benefits of screening for AFib, if and when they would recommend screening, and whether they would recommend anticoagulation for a patient with screen-detected AFib.

    更新日期:2019-12-03
  • Hepatitis C Virus Screening and Care: Complexity of Implementation in Primary Care Practices Serving Disadvantaged Populations
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-12-03
    Barbara J. Turner, Andrea Rochat, Sarah Lill, Raudel Bobadilla, Ludivina Hernandez, Aro Choi, Juan A. Guerrero

    Background: Hepatitis C virus (HCV) disproportionately affects disadvantaged communities. Objective: To examine processes and outcomes of Screen, Treat, Or Prevent Hepatocellular Carcinoma (STOP HCC), a multicomponent intervention for HCV screening and care in safety-net primary care practices. Design: Mixed-methods retrospective analysis. Setting: 5 federally qualified health centers (FQHCs) and 1 family medicine residency program serving low-income communities in diverse locations with largely Hispanic populations. Patients: Persons born in 1945 through 1965 (baby boomers) who had never been tested for HCV and were followed through May 2018. Intervention: The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model guided implementation and evaluation. Test costs were covered for uninsured patients. Measurements: All practices tested patients for anti-HCV antibody (anti-HCV) and HCV RNA. For uninsured patients with chronic HCV in 4 practices, quantitative data also enabled assessment of HCV staging, specialist teleconsultation, direct-acting antiviral (DAA) treatment, and sustained virologic response (SVR). Implementation fidelity and adaptation were assessed qualitatively. Results: Anti-HCV screening was done in 13 334 of 27 700 baby boomers (48.1%, varying by practice from 19.8% to 71.3%). Of 695 anti-HCV–positive patients, HCV RNA was tested in 520 (74.8%; 48.9% to 92.9% by practice), and 349 persons (2.6% of those screened) were diagnosed with chronic HCV. In 4 FQHCs, 174 (84.9%) of 205 uninsured patients with chronic HCV had disease staging, 145 (70.7%) had teleconsultation review, 119 (58.0%) were recommended to start DAA therapy, 82 (40.0%) initiated free DAA therapy, 74 (36.1%) completed therapy (27.8% to 60.0% by practice), and 70 (94.6% of DAA completers) achieved SVR. Implementation was promoted by multilevel practice engagement, patient navigation, and anti-HCV screening with reflex HCV RNA testing. Limitation: No control practices were included, and data were missing for some variables. Conclusion: Despite a similar framework for STOP HCC implementation, performance varied widely across safety-net practices, which may reflect practice engagement as well as infrastructure or cost challenges beyond practice control. Primary Funding Source: Cancer Prevention & Research Institute of Texas and Centers for Medicare & Medicaid Services.

    更新日期:2019-12-03
  • Altered Risk for Cardiovascular Events With Changes in the Metabolic Syndrome Status
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-26

    What is the problem and what is known about it so far? Metabolic syndrome is a group of 5 risk factors—increased blood pressure, high blood sugar level, excess abdominal fat, high triglyceride level, and unhealthy cholesterol levels—that increase the likelihood of developing heart disease and stroke. Metabolic syndrome has become a growing public health problem worldwide. Why did the researchers do this particular study? Previous studies have compared people with metabolic syndrome versus those without it. However, how cardiovascular disease risk would change if a person develops or recovers from metabolic syndrome is not clear. The objective of this population-based study was to evaluate the risk for major cardiovascular diseases among adults who develop or recover from metabolic syndrome. Who was studied? 9,553,042 adults (aged ≥20 years) who received general health screenings from the National Health Insurance Service of Korea from 2009 to 2014. How was the study done? Study participants were divided into the following 4 groups depending on their metabolic syndrome status during 3 consecutive general health examinations: those who chronically remained in metabolic syndrome state, those with newly developed metabolic syndrome, those who recovered from metabolic syndrome, and those who remained free of metabolic syndrome. The researchers compared the risks for developing cardiovascular diseases or strokes among these 4 groups. What did the researchers find? Participants who recovered from metabolic syndrome had a reduced risk for cardiovascular disease compared with those who remained in the metabolic syndrome state. On the other hand, participants with newly developed metabolic syndrome had significantly higher risk for cardiovascular disease than those who remained free of the condition. What were the limitations of the study? Participants in the 4 groups may be different in ways other than their metabolic syndrome status, and these differences may influence their risk for cardiovascular disease. Also, follow-up was relatively short. What are the implications of the study? For people with preexisting metabolic syndrome, it is not too late to actively seek treatment of this condition to reduce risk for cardiovascular disease. People without metabolic syndrome should adopt measures to prevent it to avoid increased risk for cardiovascular disease.

    更新日期:2019-11-26
  • Annals Graphic Medicine - Fear and Loathing in RA
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-26
    Jennifer Ng

    更新日期:2019-11-26
  • Breast Cancer Screening and Diagnosis: A Synopsis of the European Breast Guidelines
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-26
    Holger J. Schünemann, Donata Lerda, Cecily Quinn, Markus Follmann, Pablo Alonso-Coello, Paolo Giorgi Rossi, Annette Lebeau, Lennarth Nyström, Mireille Broeders, Lydia Ioannidou-Mouzaka, Stephen W. Duffy, Bettina Borisch, Patricia Fitzpatrick, Solveig Hofvind, Xavier Castells, Livia Giordano, Carlos Canelo-Aybar, Sue Warman, Robert Mansel, Francesco Sardanelli, Elena Parmelli, Axel Gräwingholt, Zuleika Saz-Parkinson

    Description: The European Commission Initiative for Breast Cancer Screening and Diagnosis guidelines (European Breast Guidelines) are coordinated by the European Commission's Joint Research Centre. The target audience for the guidelines includes women, health professionals, and policymakers. Methods: An international guideline panel of 28 multidisciplinary members, including patients, developed questions and corresponding recommendations that were informed by systematic reviews of the evidence conducted between March 2016 and December 2018. GRADE (Grading of Recommendations Assessment, Development and Evaluation) Evidence to Decision frameworks were used to structure the process and minimize the influence of competing interests by enhancing transparency. Questions and recommendations, expressed as strong or condi-tional, focused on outcomes that matter to women and provided a rating of the certainty of evidence. Recommendations: This synopsis of the European Breast Guidelines provides recommendations regarding organized screening programs for women aged 40 to 75 years who are at average risk. The recommendations address digital mammography screening and the addition of hand-held ultrasonography, automated breast ultrasonography, or magnetic resonance imaging compared with mammography alone. The recommendations also discuss the frequency of screening and inform decision making for women at average risk who are recalled for suspicious lesions or who have high breast density.

    更新日期:2019-11-26
  • Altered Risk for Cardiovascular Events With Changes in the Metabolic Syndrome Status: A Nationwide Population-Based Study of Approximately 10 Million Persons
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-26
    Sehoon Park, Soojin Lee, Yaerim Kim, Yeonhee Lee, Min Woo Kang, Kyungdo Han, Seung Seok Han, Hajeong Lee, Jung Pyo Lee, Kwon Wook Joo, Chun Soo Lim, Yon Su Kim, Dong Ki Kim

    Background: Population-scale evidence for the association between dynamic changes in metabolic syndrome (MetS) status and alterations in the risk for major adverse cardiovascular events (MACE) is lacking. Objective: To investigate whether recovery from or development of MetS in a population is associated with an altered risk for MACE. Design: Nationwide cohort study. Setting: An analysis based on the National Health Insurance Database of Korea. Participants: A total of 27 161 051 persons who received national health screenings from 2009 to 2014 were screened. Those with a history of MACE were excluded. We determined the MetS status of 9 553 042 persons using the following harmonizing criteria: MetS-chronic (n = 1 486 485), MetS-developed (n = 587 088), MetS-recovery (n = 538 806), and MetS-free (n = 6 940 663). Measurements: The outcome was the occurrence of MACE, including acute myocardial infarction, revascularization, and acute ischemic stroke, identified from the claims database. The incidence rate ratios (IRRs) were calculated with adjustments for body mass index, comorbidity scores, previous metabolic variables, and other clinical or demographic variables. Results: At a median follow-up of 3.54 years, the MetS-recovery group (incidence rate, 4.55 per 1000 person-years) had a significantly lower MACE risk (adjusted IRR, 0.85 [95% CI, 0.83 to 0.87]) than that of the MetS-chronic group (incidence rate, 8.52 per 1000 person-years). The MetS-developed group (incidence rate, 6.05 per 1000 person-years) had a significantly higher MACE risk (adjusted IRR, 1.36 [CI, 1.33 to 1.39]) than that of the MetS-free group (incidence rate, 1.92 per 1000 person-years). Among the MetS components, change in hypertension was associated with the largest difference in MACE risk. Limitation: Limited assessment of mortality and short follow-up. Conclusion: Recovery from MetS was significantly associated with decreased risk for MACE, whereas development of MetS was associated with increased risk. Primary Funding Source: Korea Healthcare Technology R&D Project, Ministry of Health and Welfare, Republic of Korea.

    更新日期:2019-11-26
  • Annals Graphic Medicine - Progress Notes: Senior
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-19
    Michael Natter

    更新日期:2019-11-21
  • Annals On Call - Bedside Ultrasonography Versus Physical Examination to Diagnose Cardiac Disease
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-19
    Robert M. Centor, Renee Dversdal

    In this episode of Annals On Call, Dr. Centor discusses the appropriate use of focused bedside cardiac ultrasonography with Dr. Renee Dversdal of Oregon Health & Science University. Listen now. Annals articles discussed include... Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysis: https://annals.org/aim/fullarticle/2747507/comparative-accuracy-focused-cardiac-ultrasonography-clinical-examination-left-ventricular-dysfunction Yes We (S)can!: https://annals.org/aim/fullarticle/2747508/yes-we-s-can About Annals On Call Annals On Call focuses on a clinically influential article published in Annals of Internal Medicine. Dr. Robert Centor shares his own perspective on the material and interviews topic area experts to discuss, debate, and share diverse insights about patient care and health care delivery. For more information on Annals On Call and for more episodes, visit go.annals.org/OnCall.

    更新日期:2019-11-20
  • Annals for Hospitalists - 19 November 2019
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-19
    David H. Wesorick, Vineet Chopra

    Inpatient Notes Reaching for Higher Value in Health Care by Bringing Together Clinicians and Researchers: The Michigan Program on Value Enhancement Geoffrey D. Barnes, MD, MSc, and Eve A. Kerr, MD, MPH Hospitalists frequently serve as clinical leaders of quality improvement projects. In this commentary, the authors discuss how partnering with researchers can make these projects more scientifically rigorous and more successful. Highlights of Recent Articles from Annals of Internal Medicine Incidence of Bloodstream Infections, Length of Hospital Stay, and Survival in Patients With Recurrent Clostridioides difficile Infection Treated With Fecal Microbiota Transplantation or Antibiotics: A Prospective Cohort Study Ann Intern Med. Published 5 November 2019. doi: 10.7326/M18-3635 This prospective cohort study compared the rates of blood stream infections (BSIs) in patients who were hospitalized with recurrent Clostridioides difficile infection (CDI). A total of 109 patients were treated with fecal microbiota transplantation, and 181 were treated with antibiotics. The study demonstrated a large difference in the rate of BSI between the 2 groups, with 5% of FMT patients developing BSI in the subsequent 90 days, compared with 22% in antibiotic-treated patients. Secondary outcomes were also very different between these groups, with an 8% 90-day mortality in the FMT group, compared with 39% in the antibiotic group. The groups differed significantly in several baseline characteristics, including number of recurrences and severity of CDI. Propensity score matching was only possible for 57 patients in each treatment group, and significant between-group differences remained. In the matched cohort, BSI occurred in 4% of FMT patients and in 26% of those treated with antibiotics. Key points for hospitalists include: In this study, patients admitted with recurrent CDI that were treated with FMT had significantly lower rates of BSI than patients treated with antibiotics. FMT patients also experienced significantly shorter lengths of stay and higher rates of CDI cure and survival at 90 days. These data suggest that FMT may be a superior treatment for recurrent CDI in this patient population. However, the observational nature of the study and the significant differences between the 2 treatment groups make it impossible to draw firm conclusions. Randomized controlled trials will be required to accurately compare the outcomes of these treatment strategies in this patient population. Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome: A Randomized Noninferiority Trial Ann Intern Med. Published 15 October 2019. doi: 10.7326/M19-0291 This multicenter, open label, randomized noninferiority trial examined whether rivaroxaban is noninferior to dose-adjusted warfarin for secondary thromboprophylaxis in antiphospholipid syndrome (APS). The study recruited 190 adults with confirmed thrombotic APS, randomly assigned them to receive rivaroxaban or warfarin (n = 95 each), and followed them over 3 years (2014–2017). The study population had high thrombotic risk (90% of patients in both groups had a high global antiphospholipid score, and 60% had triple positivity of lupus anticoagulants, anticardiolipin, and anti–β2-glycoprotein I antibodies). The prespecified noninferiority margin for the risk ratio was 1.40. The primary efficacy outcome (proportion of patients with new thrombotic events) occurred in 11 patients (11.6%) in the rivaroxaban group and 6 (6.3%) in the warfarin group (risk ratio, 1.83). Thrombotic events in the rivaroxaban group were predominantly arterial, particularly stroke. There was no significant difference in bleeding rates between the groups. Key points for hospitalists include: Rivaroxaban failed to show noninferiority to warfarin for thromboprophylaxis in high-risk APS but was associated with a nonsignificant increased risk for arterial thrombosis. Reasons for rivaroxaban's higher rates of thrombosis are not clear but could be related to targeting a single coagulation factor (as opposed to several with warfarin) or treatment interruption by patients due to lack of monitoring compared with warfarin. Editorialists note that these results are consistent with a prior noninferiority study of rivaroxaban vs. warfarin in high-risk APS and suggest that warfarin remains the anticoagulant of choice for this condition. The Latest Highlights From Journal Club Is tranexamic acid safe and effective in nonsurgical bleeding? Review: In nonsurgical settings, tranexamic acid reduces mortality and does not increase thrombotic events Ann Intern Med. 2019;171:JC40. doi: 10.7326/ACPJ201910150-040 This systematic review analyzed 22 RCTs (n = 49 538) comparing treatment with tranexamic acid vs. placebo in bleeding patients. The studies included a heterogeneous population of nonsurgical bleeding conditions, including gastrointestinal bleeding, postpartum hemorrhage, heavy menstrual bleeding, and trauma. Tranexamic acid use was not associated with increased risk for thrombosis but was associated with an 8% relative risk reduction for mortality. The inclusion of many causes of bleeding (with varied levels of risk) limits the study's conclusions. Is alteplase effective for ischemic stroke treatment in a 4.5- to 9-hour time window? Pooled RCTs: In acute ischemic stroke with salvageable brain tissue alteplase at 4.5 to 9 hours improved function Ann Intern Med. 2019;171:JC44. doi: 10.7326/ACPJ201910150-044 This meta-analysis of 3 RCTs concludes that alteplase vs. placebo in patients presenting with acute ischemic stroke at 4.5 to 9 hours after symptom onset (or wake-up stroke), and having evidence of salvageable brain tissue on perfusion imaging studies, results in early neurologic improvement at 48 hours and improved function at 3-month follow-up. Sign up here to have Annals for Hospitalists delivered to your inbox each month.

    更新日期:2019-11-20
  • Annals for Educators - 19 November 2019
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-19
    Darren B. Taichman

    Clinical Practice Points Rivaroxaban Versus Vitamin K Antagonist in Antiphospholipid Syndrome. A Randomized Noninferiority Trial Long-term anticoagulation with vitamin K antagonists (VKAs) is the standard of care for preventing thrombosis in patients with antiphospholipid antibody syndrome (APS), but VKAs require frequent monitoring and are associated with food and drug interactions. This 3-year randomized controlled trial compared the efficacy and safety of a newer oral anticoagulant versus dose-adjusted VKAs in patients with APS. Use this study to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners when a diagnosis of APS should be considered. What are the possible clinical manifestations? How is APS treated? Use the information in DynaMed: Antiphospholipid Antibody Syndrome, a benefit of your ACP membership! Ask your learners what a noninferiority study is. What does the noninferiority margin mean? How are the results interpreted? The authors present the results of “intention-to-treat” and “per protocol” analyses. What is the difference? What are the potential biases introduced by a per protocol analysis? Why might a per protocol analysis be useful? Why might rivaroxaban not be noninferior to dose-adjusted VKAs in this study? The authors offer some possible explanations in the discussion. Invite an expert in study design to join your discussion. Incidence of Bloodstream Infections, Length of Hospital Stay, and Survival in Patients With Recurrent Clostridioides difficile Infection Treated With Fecal Microbiota Transplantation or Antibiotics. A Prospective Cohort Study Fecal microbiota transplantation (FMT) aims to restore the normal composition of gut microbiota and is recommended for treatment of recurrent Clostridioides difficile infection (CDI). Restoration of healthy microbiota through FMT might also prevent CDI-associated bloodstream infections. The objective of this prospective cohort study was to compare the incidence of bloodstream infections in patients with recurrent CDI treated with either FMT or antibiotics. Use this study to: Ask your learners why recurrent CDI might be a life-threatening condition. What are the potential complications? Why might patients with recurrent CDI be at increased risk for bloodstream infections? Which ones? How is recurrent CDI treated? Is FMT used at your center? What were the outcomes of this study? What are the limitations of an observational study (versus a randomized trial) to compare 2 approaches to therapy? What is the goal of propensity score matching? How well does this approach mimic a randomized trial? Invite an expert in biostatistics to join your discussion. Annals for Hospitalists Inpatient Notes - Reaching for Higher Value in Health Care by Bringing Together Clinicians and Researchers—The Michigan Program on Value Enhancement This short essay summarizes the steps used to assess a problem within a health system, devise a solution, plan how to study the effect of the solution, and assess its success. Use this paper to: Invite your learners to identify a problem with the system in which they practice every day. Can they identify the causes of the problem? What are potential ways to fix it? Invite an expert in quality improvement to join your discussion. Could your learners work to test a solution to the problem they identified? Video Learning Annals Consult Guys - Procedures With DOACs: How Long to Wait? Howard and Geno tackle the challenge of managing direct oral anticoagulants (DOACs) when an invasive procedure is planned. Use this feature to: Ask your learners to list the available DOACs. What are their mechanisms of action? Can they be reversed in the event of bleeding? Watch the video. Then, ask how to calculate the time required after stopping the DOAC before an invasive procedure. Humanism and Professionalism On Being a Doctor: A Portrait of the Physician as a Young Man Dr. Ross describes how the tired physician recalls himself as a boy and wonders, “Who was that boy—that confident creator?” Use this essay to: Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners what professions they thought they would pursue when they were younger. What drew them to each? Are there aspects of medicine that encompass the talents involved in those other professions? MKSAP 18 Question A 32-year-old woman is evaluated for a recent episode of transient left monocular blindness. She noted dimness of vision in the left eye that came on suddenly and persisted for 15 minutes and then resolved completely. She had no accompanying headache or other symptoms. She has an 8-year history of systemic lupus erythematosus, which initially manifested as photosensitivity, discoid rash, and arthritis. She has responded well to treatment and has been doing well without active disease for the past year. History is significant for recurrent first trimester pregnancy loss attributed to positive antiphospholipid and anticardiolipin antibodies. Medications are hydroxychloroquine, prednisone, aspirin, and a daily multivitamin. On physical examination, vital signs are normal. Cardiac rhythm is normal. A 2/6 holosystolic murmur is heard at the apex with radiation toward the axilla. Temporal and carotid artery pulsations are normal; there is no scalp tenderness or vascular bruits. The remainder of the physical examination, including ophthalmologic examination, is normal. Which of the following is the most likely cause of her visual symptom? A. Bacterial endocarditis B. Carotid artery stenosis C. Giant cell arteritis D. Libman-Sacks endocarditis Correct Answer D. Libman-Sacks endocarditis Educational Objective Diagnose Libman-Sacks endocarditis. Critique Libman-Sacks endocarditis (nonbacterial thrombotic endocarditis) is the most likely cause of this patient's transient monocular blindness. She has an 8-year history of systemic lupus erythematosus (SLE) and positive antiphospholipid antibodies (anticardiolipin antibodies plus lupus anticoagulant) with recurrent pregnancy loss. She meets the criteria for antiphospholipid syndrome. Patients who have SLE with positive antiphospholipid antibodies are at a high risk for developing valvular dysfunction/thickening, and in some cases manifesting as Libman-Sacks endocarditis. A recent study confirmed this significant association between valvular heart disease and antiphospholipid antibody positivity. It was also found that the highest risk was seen in double-positive antiphospholipid antibodies/lupus anticoagulant patients, as is the case in this patient. Libman-Sacks endocarditis may affect 11% or more of patients with SLE and has no relationship to disease activity. The condition is associated with large verrucous lesions near the edge of the valve, most often the mitral valve. Typical lesions consist of immune complexes, mononuclear cells, and fibrin and platelet thrombi. Libman-Sacks endocarditis is usually asymptomatic but can be responsible for numerous complications, including embolic stroke, or in this case a transient ischemic attack in the territory of the ophthalmic artery, peripheral emboli, and infective endocarditis. Bacterial endocarditis can be a source of cardiogenic emboli, but 90% of patients with infective endocarditis have fever, and often other constitutional symptoms, which are absent in this patient. Patients with SLE are prone to develop premature atherosclerosis (and can be a cause of stroke or transient ischemia attack), but this patient has no findings of atherosclerosis involving the carotid artery; furthermore, this diagnosis cannot account for the patient's heart murmur. Transient monocular blindness can be a manifestation of giant cell arteritis, but this diagnosis is extremely rare in individuals less than 40 years old. Key Point Patients with systemic lupus erythematosus and positive antiphospholipid antibodies are at a high risk for developing valvular dysfunction/thickening, in some cases manifesting as Libman-Sacks endocarditis. Bibliography Vivero F, Gonzalez-Echavarri C, Ruiz-Estevez B, Maderuelo I, Ruiz-Irastorza G. Prevalence and predictors of valvular heart disease in patients with systemic lupus erythematosus. Autoimmun Rev. 2016;15:1134-1140. doi:10.1016/j.autrev.2016.09.007 Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.

    更新日期:2019-11-20
  • Annals Consult Guys - Procedures With DOACs: How Long to Wait?
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-19
    Geno J. Merli, Howard H. Weitz

    Annals Consult Guys brings a new perspective to the art and science of medicine with lively discussion and analysis of real-world cases and situations. They address medically relevant topics—whether they be poignant, thought-provoking, or just plain entertaining. For more videos from and information on Annals Consult Guys, visit go.annals.org/ConsultGuys.

    更新日期:2019-11-20
  • The Management of Stroke Rehabilitation: A Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-19
    James Sall, Blessen C. Eapen, Johanna Elizabeth Tran, Amy O. Bowles, Andrew Bursaw, M. Eric Rodgers

    Description: In June 2019, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved an update of the joint clinical practice guideline for rehabilitation after stroke. This synopsis summarizes the key recommendations from this guideline. Methods: In February 2018, the VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included clinical stakeholders and stroke survivors and conformed to the National Academy of Medicine (formerly the Institute of Medicine) tenets for trustworthy clinical practice guidelines. The guideline panel identified key questions, systematically searched and evaluated the literature, and developed 2 algorithms and 42 key recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Stroke survivors and their family members were invited to share their perspectives to further inform guideline development. Recommendations: The guideline recommendations provide evidence-based guidance for the rehabilitation care of patients after stroke. The recommendations are applicable to health care providers in both primary care and rehabilitation. Key features of the guideline are recommendations in 6 areas: timing and approach; motor therapy; dysphagia; cognitive, speech, and sensory therapy; mental health therapy; and other functions, such as returning to work and driving.

    更新日期:2019-11-20
  • Presenting Risks and Benefits: Helping the Data Monitoring Committee Do Its Job
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-19
    Scott R. Evans, Robert Bigelow, Christy Chuang-Stein, Susan S. Ellenberg, Paul Gallo, Weili He, Qi Jiang, Frank Rockhold

    Data monitoring committees (DMCs), or data and safety monitoring boards, protect clinical trial participants by conducting benefit–risk assessments during the course of a clinical trial. These evaluations may be improved by broader access to data and more effective analyses and presentation. Data monitoring committees should have access to all data, including efficacy data, at each interim review. The DMC reports should include graphical presentations that summarize benefits and harms in efficient ways. Benefit–risk assessments should include summaries that are consistent with the intention-to-treat principle and have a pragmatic focus. This article provides examples of graphical summaries that integrate benefits and harms, and proposes that such summaries become standard in DMC reports.

    更新日期:2019-11-20
  • Treatments for Poststroke Motor Deficits and Mood Disorders: A Systematic Review for the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Stroke Rehabilitation
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-19
    Kristen E. D'Anci, Stacey Uhl, Jeffrey Oristaglio, Nancy Sullivan, Amy Y. Tsou

    Background: Early rehabilitation after stroke is essential to help reduce disability. Purpose: To summarize evidence on the benefits and harms of nonpharmacologic and pharmacologic treatments for motor deficits and mood disorders in adults who have had stroke. Data Sources: English-language searches of multiple electronic databases from April 2009 through July 2018; targeted searches to December 2018 for studies of selective serotonin reuptake inhibitors (SSRIs) or serotonin–norepinephrine reuptake inhibitors. Study Selection: 19 systematic reviews and 37 randomized controlled trials addressing therapies for motor deficits or mood disorders in adults with stroke. Data Extraction: One investigator abstracted the data, and quality and GRADE assessment were checked by a second investigator. Data Synthesis: Most interventions (for example, SSRIs, mental practice, mirror therapy) did not improve motor function. High-quality evidence did not support use of fluoxetine to improve motor function. Moderate-quality evidence supported use of cardiorespiratory training to improve maximum walking speed and repetitive task training or transcranial direct current stimulation to improve activities of daily living (ADLs). Low-quality evidence supported use of robotic arm training to improve ADLs. Low-quality evidence indicated that antidepressants may reduce depression, whereas the frequency and severity of antidepressant-related adverse effects was unclear. Low-quality evidence suggested that cognitive behavioral therapy and exercise, including mind–body exercise, may reduce symptoms of depression and anxiety. Limitation: Studies were of poor quality, interventions and comparators were heterogeneous, and evidence on harms was scarce. Conclusion: Cardiorespiratory training, repetitive task training, and transcranial direct current stimulation may improve ADLs in adults with stroke. Cognitive behavioral therapy, exercise, and SSRIs may reduce symptoms of poststroke depression, but use of SSRIs to prevent depression or improve motor function was not supported. Primary Funding Source: U.S. Department of Veterans Affairs, Veterans Health Administration.

    更新日期:2019-11-20
  • Bedside Optic Nerve Ultrasonography for Diagnosing Increased Intracranial Pressure: A Systematic Review and Meta-analysis
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-19
    Alex Koziarz, Niv Sne, Fraser Kegel, Siddharth Nath, Jetan H. Badhiwala, Farshad Nassiri, Alireza Mansouri, Kaiyun Yang, Qi Zhou, Timothy Rice, Samir Faidi, Edward Passos, Andrew Healey, Laura Banfield, Mark Mensour, Andrew W. Kirkpatrick, Aussama Nassar, Michael G. Fehlings, Gregory W.J. Hawryluk, Saleh A. Almenawer

    Background: Optic nerve ultrasonography (optic nerve sheath diameter sonography) has been proposed as a noninvasive, quick method for diagnosing increased intracranial pressure. Purpose: To examine the accuracy of optic nerve ultrasonography for diagnosing increased intracranial pressure in children and adults. Data Sources: 13 databases from inception through May 2019, reference lists, and meeting proceedings. Study Selection: Prospective optic nerve ultrasonography diagnostic accuracy studies, published in any language, involving any age group or reference standard. Data Extraction: 3 reviewers independently abstracted data and performed quality assessment. Data Synthesis: Of 71 eligible studies involving 4551 patients, 61 included adults, and 35 were rated as having low risk of bias. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of optic nerve ultrasonography in patients with traumatic brain injury were 97% (95% CI, 92% to 99%), 86% (CI, 74% to 93%), 6.93 (CI, 3.55 to 13.54), and 0.04 (CI, 0.02 to 0.10), respectively. Respective estimates in patients with nontraumatic brain injury were 92% (CI, 86% to 96%), 86% (CI, 77% to 92%), 6.39 (CI, 3.77 to 10.84), and 0.09 (CI, 0.05 to 0.17). Accuracy estimates were similar among studies stratified by patient age, operator specialty and training level, reference standard, sonographer blinding status, and cutoff value. The optimal cutoff for optic nerve sheath dilatation on ultrasonography was 5.0 mm. Limitation: Small studies, imprecise summary estimates, possible publication bias, and no evaluation of effect on clinical outcomes. Conclusion: Optic nerve ultrasonography can help diagnose increased intracranial pressure. A normal sheath diameter measurement has high sensitivity and a low negative likelihood ratio that may rule out increased intracranial pressure, whereas an elevated measurement, characterized by a high specificity and positive likelihood ratio, may indicate increased intracranial pressure and the need for additional confirmatory tests. Primary Funding Source: None. (PROSPERO: CRD42017055485)

    更新日期:2019-11-20
  • The Effect of Technology-Based Coaching on Maintenance of Weight Loss
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-12

    What is the problem and what is known about it so far? Most weight management programs focus on weight loss rather than weight maintenance. A few trials have focused on weight maintenance but delivered the intervention outside routine primary care or did not involve primary care providers. Why did the researchers do this particular study? The researchers wanted to see whether an intervention that provided personalized health coaching through an electronic patient portal and support to primary care providers had an effect on weight change in primary care patients who intentionally lost a large amount of weight. Who was studied? The study involved 194 patients who had lost 5% or more of their body weight on purpose during the previous 2 years and had access to a computer that was connected to the Internet. Patients who were pregnant and those who had a history of cancer or bariatric surgery were not eligible for the study. How was the study done? The patients were randomly assigned to the intervention group or a tracking group. Both groups were told to enter information about their weight, diet, and exercise into the computer every day. Patients in the intervention group received 2 years of personalized health coaching through the electronic patient portal. In addition, their primary care providers received status reports in real time on the patients' weights, were notified about weight change of 10 pounds or more, and were given annual progress reports. The tracking group received questionnaires on various health concerns (such as vaccinations). The patients were seen for measurement visits every 6 months, and researchers compared weight changes at 24 months between the groups. What did the researchers find? Most of the patients in the study were female and white. At 24 months, the intervention group showed less weight regain than the tracking group, and the difference in weight change between groups was significant. What were the limitations of the study? The study was conducted at a single institution, and the sample included few men and nonwhite participants. What are the implications of the study? Among patients who purposely lost a significant amount of weight, personalized coaching that was delivered through an electronic patient portal resulted in less weight regain.

    更新日期:2019-11-13
  • 更新日期:2019-11-13
  • Policy Recommendations for Public Health Plans to Stem the Escalating Costs of Prescription Drugs: A Position Paper From the American College of Physicians
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-12
    Hilary Daniel, Sue S. Bornstein

    The increasing price of prescription drugs is an ongoing concern for Medicare and Medicaid, particularly for patients with chronic health conditions who are using multiple medications and patients in these programs taking high-priced brand-name specialty drugs. Shifts in benefit design, including higher deductibles and a movement away from copayments to coinsurance, have increased patient out-of-pocket costs and put pressure on program budgets. In this paper, the American College of Physicians expands on its position paper from 2016 and offers additional recommendations to decrease out-of-pocket costs for patients, enhance the government's purchasing power, and address existing policies that add costs to the health care system.

    更新日期:2019-11-13
  • Policy Recommendations for Pharmacy Benefit Managers to Stem the Escalating Costs of Prescription Drugs: A Position Paper From the American College of Physicians
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-12
    Hilary Daniel, Sue S. Bornstein

    Recent discussions about the increasing prices of prescription drugs have focused on pharmacy benefit managers (PBMs), third-party intermediaries for various types of employers and government purchasers who negotiate drug prices in health plans and thus play a crucial role in determining the amount millions of Americans pay for medications. In this position paper, the American College of Physicians expands on its position paper from 2016 by offering additional recommendations to improve transparency in the PBM industry and highlighting the need for reliable, timely, and relevant information on prescription drug pricing for physicians and patients.

    更新日期:2019-11-13
  • The Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-12
    David M. Kent, Jessica K. Paulus, David van Klaveren, Ralph D'Agostino, Steve Goodman, Rodney Hayward, John P.A. Ioannidis, Bray Patrick-Lake, Sally Morton, Michael Pencina, Gowri Raman, Joseph S. Ross, Harry P. Selker, Ravi Varadhan, Andrew Vickers, John B. Wong, Ewout W. Steyerberg

    Heterogeneity of treatment effect (HTE) refers to the nonrandom variation in the magnitude or direction of a treatment effect across levels of a covariate, as measured on a selected scale, against a clinical outcome. In randomized controlled trials (RCTs), HTE is typically examined through a subgroup analysis that contrasts effects in groups of patients defined “1 variable at a time” (for example, male vs. female or old vs. young). The authors of this statement present guidance on an alternative approach to HTE analysis, “predictive HTE analysis.” The goal of predictive HTE analysis is to provide patient-centered estimates of outcome risks with versus without the intervention, taking into account all relevant patient attributes simultaneously. The PATH (Predictive Approaches to Treatment effect Heterogeneity) Statement was developed using a multidisciplinary technical expert panel, targeted literature reviews, simulations to characterize potential problems with predictive approaches, and a deliberative process engaging the expert panel. The authors distinguish 2 categories of predictive HTE approaches: a “risk-modeling” approach, wherein a multivariable model predicts the risk for an outcome and is applied to disaggregate patients within RCTs to define risk-based variation in benefit, and an “effect-modeling” approach, wherein a model is developed on RCT data by incorporating a term for treatment assignment and interactions between treatment and baseline covariates. Both approaches can be used to predict differential absolute treatment effects, the most relevant scale for clinical decision making. The authors developed 4 sets of guidance: criteria to determine when risk-modeling approaches are likely to identify clinically important HTE, methodological aspects of risk-modeling methods, considerations for translation to clinical practice, and considerations and caveats in the use of effect-modeling approaches. The PATH Statement, together with its explanation and elaboration document, may guide future analyses and reporting of RCTs.

    更新日期:2019-11-13
  • The Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement: Explanation and Elaboration
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-12
    David M. Kent, David van Klaveren, Jessica K. Paulus, Ralph D'Agostino, Steve Goodman, Rodney Hayward, John P.A. Ioannidis, Bray Patrick-Lake, Sally Morton, Michael Pencina, Gowri Raman, Joseph S. Ross, Harry P. Selker, Ravi Varadhan, Andrew Vickers, John B. Wong, Ewout W. Steyerberg

    The PATH (Predictive Approaches to Treatment effect Heterogeneity) Statement was developed to promote the conduct of, and provide guidance for, predictive analyses of heterogeneity of treatment effects (HTE) in clinical trials. The goal of predictive HTE analysis is to provide patient-centered estimates of outcome risk with versus without the intervention, taking into account all relevant patient attributes simultaneously, to support more personalized clinical decision making than can be made on the basis of only an overall average treatment effect. The authors distinguished 2 categories of predictive HTE approaches (a “risk-modeling” and an “effect-modeling” approach) and developed 4 sets of guidance statements: criteria to determine when risk-modeling approaches are likely to identify clinically meaningful HTE, methodological aspects of risk-modeling methods, considerations for translation to clinical practice, and considerations and caveats in the use of effect-modeling approaches. They discuss limitations of these methods and enumerate research priorities for advancing methods designed to generate more personalized evidence. This explanation and elaboration document describes the intent and rationale of each recommendation and discusses related analytic considerations, caveats, and reservations.

    更新日期:2019-11-13
  • Effect of Electronic Health Record–Based Coaching on Weight Maintenance: A Randomized Trial
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-12
    Molly B. Conroy, Kathleen M. McTigue, Cindy L. Bryce, Dana Tudorascu, Bethany Barone Gibbs, Jonathan Arnold, Diane Comer, Rachel Hess, Kimberly Huber, Laurey R. Simkin-Silverman, Gary S. Fischer

    Background: Weight regain after intentional loss is common. Most evidence-based weight management programs focus on short-term loss rather than long-term maintenance. Objective: To evaluate the benefit of coaching in an electronic health record (EHR)–based weight maintenance intervention. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT01946191) Setting: Practices affiliated with an academic medical center. Participants: Adult outpatients with body mass index (BMI) of 25 kg/m2 or higher, intentional weight loss of at least 5% in the previous 2 years, and no bariatric procedures in the previous 5 years. Intervention: Participants were randomly assigned to EHR tools (tracking group) versus EHR tools plus coaching (coaching group). The EHR tools included weight, diet, and physical activity tracking flow sheets; standardized surveys; and reminders. The coaching group received 24 months of personalized coaching through the EHR patient portal, with 24 scheduled contacts. Measurements: The primary outcome was weight change at 24 months. Secondary outcomes included 5% weight loss maintenance and changes in BMI, waist circumference, number of steps per day, health-related quality of life, physical function, blood pressure, and satisfaction. Results: Among 194 randomly assigned participants (mean age, 53.4 years [SD, 12.2]; 143 [74%] women; 171 [88%] white), 157 (81%) completed the trial. Mean baseline weight and BMI were 85.8 kg (SD, 19.1) and 30.4 kg/m2 (SD, 5.9). At 24 months, mean weight regain (± SE) was 2.1 ± 0.62 kg and 4.9 ± 0.63 kg in the coaching and tracking groups, respectively. The between-group difference in weight change at 24 months was significant (−2.86 kg [95% CI, −4.60 to −1.11 kg]) in the linear mixed model. At 24 months, 65% of participants in the coaching group and 50% in the tracking group maintained weight loss of at least 5%. Limitation: Single-site trial, which limits generalizability. Conclusion: Among adults with intentional weight loss of at least 5%, use of EHR tools plus coaching resulted in less weight regain than EHR tools alone. Primary Funding Source: Agency for Healthcare Research and Quality and National Institutes of Health.

    更新日期:2019-11-13
  • Compassionate End-of-Life Care: Mixed-Methods Multisite Evaluation of the 3 Wishes Project
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-12
    Meredith Vanstone, Thanh H. Neville, France J. Clarke, Marilyn Swinton, Marina Sadik, Alyson Takaoka, Orla Smith, Andrew J. Baker, Allana LeBlanc, Denise Foster, Vinay Dhingra, Peter Phung, Xueqing (Sherry) Xu, Yuhan Kao, Diane Heels-Ansdell, Benjamin Tam, Feli Toledo, Anne Boyle, Deborah J. Cook

    Background: The 3 Wishes Project (3WP) is an end-of-life program that aims to honor the dignity of dying patients by creating meaningful patient- and family-centered memories while promoting humanistic interprofessional care. Objective: To determine whether this palliative intervention could be successfully implemented—defined as demonstrating value, transferability, affordability, and sustainability—beyond the intensive care unit in which it was created. Design: Mixed-methods formative program evaluation. (ClinicalTrials.gov: NCT04147169) Setting: 4 North American intensive care units. Participants: Dying patients, their families, clinicians, hospital managers, and administrators. Intervention: Wishes from dying patients, family members, and clinicians were elicited and implemented. Measurements: Patient characteristics and processes of care; the number, type, and cost of each wish; and semistructured interviews and focus groups with family members, clinicians, and managers. Results: A total of 730 patients were enrolled, and 3407 wishes were elicited. Qualitative data were gathered from 75 family members, 72 clinicians, and 20 managers or hospital administrators. Value included intentional comforting of families as they honored the lives and legacies of their loved ones while inspiring compassionate clinical care. Factors promoting transferability included family appreciation and a collaborative intensive care unit culture committed to dignity-conserving end-of-life care. Staff participation evolved from passive support to professional agency. Program initiation required minimal investment for reusable materials; thereafter, the mean cost was $5.19 (SD, $17.14) per wish. Sustainability was demonstrated by the continuation of 3WP at each site after study completion. Limitation: This descriptive formative evaluation describes tertiary care center–specific experiences rather than aiming for generalizability to all jurisdictions. Conclusion: The 3WP is a transferrable, affordable, and sustainable program that provides value to dying patients, their families, clinicians, and institutions. Primary Funding Source: Greenwall Foundation.

    更新日期:2019-11-13
  • Annals Story Slam - What's a Life Worth?
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-05
    Naheed Dosani

    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.

    更新日期:2019-11-05
  • Annals Story Slam - Mutata Sunt Tempora
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-05
    Sharon Walmsley

    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.

    更新日期:2019-11-05
  • Annals Story Slam - Caring
    Ann. Intern. Med. (IF 19.315) Pub Date : 2019-11-05
    Andreas Laupacis

    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.

    更新日期:2019-11-05
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