Ann Intern Med Research Articles

Components of Successful Spiritual Care.

The quantifiable health benefits of spiritual practice and religious community have inspired a movement toward addressing religion within health care and medical education, yet biomedical professionals still often avoid this topic (Giordano and Engebretson in Explore 2(3):216--225, 2006; Post et al. in Ann Intern Med 132(7):578, 2000). This is largely due to a lack of clarity on how to ethically engage with diverse spiritual practices and maintain professional boundaries regarding spiritual care. However, a majority of patients desire increased incorporation of spirituality in medical discussions, indicating a deficit in care that must be addressed (Best et al. in Patient Educ Couns 98(11):1320-1328, 2015; Zaidi in AMA J Ethics 20(7), 2018). In this article, I clarify what constitutes successful spiritual care by identifying its key components and major challenges. I then make recommendations for ethically mindful, comprehensive spiritual care and consider potential next steps including structural changes that prioritize compassion and empathy in medicine.

Clinical Risk Factors for COVID-19 Among People With Substance Use Disorders.

Back to table of contents Previous article Next article DatapointsFull AccessClinical Risk Factors for COVID-19 Among People With Substance Use DisordersHefei Wen, Ph.D., Michael L. Barnett, M.D., M.S., Brendan Saloner, Ph.D.Hefei WenSearch for more papers by this author, Ph.D., Michael L. BarnettSearch for more papers by this author, M.D., M.S., Brendan SalonerSearch for more papers by this author, Ph.D.Published Online:6 Oct 2020https://doi.org/10.1176/appi.ps.202000215AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail As COVID-19 spreads across the United States, people with substance use disorder may be susceptible to contracting the disease and developing serious complications. COVID-19 epidemiology suggests that cardiovascular and chronic respiratory diseases and diabetes may increase the risk for severe illness (1). People with opioid use disorder and methamphetamine use disorder deserve particular attention, given the detrimental effects of long-term drug use on pulmonary function, other major organ systems, and the immune system (1).We used individual‐level data from the 2015–2018 National Survey on Drug Use and Health (NSDUH). Our sample consisted of three mutually exclusive groups of civilian, noninstitutionalized adults ages 18–64: those with past-year opioid or methamphetamine use disorder, those with other types of past-year substance use disorder (i.e., abuse of or dependence on alcohol, illicit drugs other than opioid and methamphetamine, or both), and those who did not have a past-year substance use disorder (2).We used logistic regression models to estimate differences among the groups in the overall and age-stratified rates of having an underlying condition that may heighten the risk for severe illness following COVID-19 infection. Models were adjusted for gender, race-ethnicity, and urban/rural residence. We used the Stata/SE “svy” procedure to account for NSDUH’s sampling weights and complex survey design (2).Nonelderly adults with opioid or methamphetamine use disorder were most likely to have an underlying condition (adjusted rate, 44.2%; p<0.001), compared with those with other types of substance use disorder (31.4%) and those without a past-year substance use disorder (33.5%). The higher rates of having an underlying condition among those with opioid or methamphetamine use disorder were observed consistently across all age categories (Figure 1).FIGURE 1. Adjusted rates of having clinical risk factors for COVID-19 severity and mortality among nonelderly U.S. adultsaaClinical risk factors recognized by the World Health Organization and the Centers for Disease Control and Prevention and included in the National Survey on Drug Use and Health questionnaire are cardiovascular disease, hypertension, chronic respiratory diseases, diabetes, cancer, chronic liver diseases, kidney disease, and HIV/AIDS. Rate estimates and 95% confidence intervals (whisker lines) were estimated with Stata/SE.Our findings underscore that opioid and methamphetamine use disorders are associated with underlying conditions identified as risk factors for COVID-19 severity and mortality. People with these conditions are an underserved group who may need additional support to ensure equal access to testing and treatment, especially as COVID-19 continues to impose unprecedented pressures on the nation’s health care system. Social distancing, self-quarantine, and other public health measures may disrupt their access to addiction treatment (2). Additional efforts are required to mitigate those unintended disruptions.Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston (Wen); Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston (Barnett); Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (Saloner). Tami L. Mark, Ph.D., and Alexander J. Cowell, Ph.D., are editors of this column.Send correspondence to Dr. Wen ([email protected]).The authors report no financial relationships with commercial interests.References1 Volkow ND. Collision of the COVID-19 and addiction epidemics. Ann Intern Med (Epub ahead of print, April 2, 2020).Crossref, Medline, Google Scholar2 2018 National Survey on Drug Use and Health: Methodological Summary and Definitions. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2019. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHMethodsSummDefs2018/NSDUHMethodsSummDefs2018.pdfGoogle Scholar FiguresReferencesCited byDetailsCited byBehavioral Health Workforce Development in the era of COVID-19: Examples From a State-Funded Intermediary Organization26 April 2022 | Community Mental Health Journal, Vol. 58, No. 8Experiences with substance use disorder treatment during the COVID-19 pandemic: Findings from a multistate surveyInternational Journal of Drug Policy, Vol. 101The Impact of the COVID-19 Pandemic on the Practice of Forensic Medicine: An Overview8 February 2022 | Healthcare, Vol. 10, No. 2Integrated vs nonintegrated treatment for perinatal opioid use disorder: retrospective cohort studyAmerican Journal of Obstetrics & Gynecology MFM, Vol. 4, No. 1Prevalence and correlates of SARS-CoV-2 seropositivity among people who inject drugs in the San Diego-Tijuana border region22 November 2021 | PLOS ONE, Vol. 16, No. 11 Volume 71Issue 12 December 01, 2020Pages 1308-1308 Metrics Keywordssubstance use disorderCOVID-19chronic diseaserisk factorPDF download History Received 2 April 2020 Revised 19 April 2020 Accepted 13 May 2020 Published online 6 October 2020 Published in print 1 December 2020

RAPIDLY PROGRESSIVE CARDIAC TAMPONADE AND BILATERAL PLEURAL EFFUSIONS IN THE SETTING OF MENINGOCOCCEMIA

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary meningococcal pericarditis (PMP) is a rare form of purulent pericarditis that can occur in the event of N. Meningitidis bacteremia without meningitis or fulminant septicemia. This form of pericarditis can be infectious or immunologic and in either form, can cause life threatening tamponade (1). Here described is a case of rapidly evolving purulent pericarditis and pleural effusion in a patient with meningococcal bacteremia. CASE PRESENTATION: A 56 year old male with a history of HIV, and remote bacterial meningitis presented with pleuritic chest pain, worsened in the supine position, fevers, and diaphoresis. At the initial time of presentation ECG findings were consistent with pericarditis and bedside echo showed minimal pericardial effusion. The patient was evaluated and due to persistent hypotension, was admitted to the MICU. Hours after admission, the patient developed worsened chest pain, in the setting of continued hypotension. A bedside echo and CTPE showed increasing pericardial effusion with tamponade physiology, as well as small developing pleural effusions. Urgent pericardiocentesis was performed, 350mL of purulent fluid was obtained and a pericardial drain placed. Pericardial fluid cultures were negative, but blood cultures grew Neisseria meningitidis. Antibiotics were deescalated from piperacillin-tazobactam to ceftriaxone at that time. Serial bedside ultrasounds and showed a on hospital day three showed rapidly increasing pleural effusions despite pericardial drain placement. A right sided diagnostic thoracentesis was performed that was exudative by Lights Criteria and class 2 with a pH 7.45 and glucose 177. The following day, left sided thoracentesis was performed, and the patient had improvement in his hypoxia and symptomatology. He was discharged home to complete a 14 day course of ceftriaxone. DISCUSSION: The most common forms of invasive meningococcal disease are septicemia and meningitis. Approximately 10% of the population is a carrier of N. menigitidis, but invasive disease is relatively rare (2). Other sites of involvement are less common, but pericarditis has been reported in meningococcal bacteremia. This most often occurs in the presence of meningococcal meningitis or fulminant septicemia (3). This patient had no signs of meningitis or fulminant sepsis at the time of presentation. Rapid accumulation of purulent fluid causing cardiac tamponade has been described in PMP (4). CONCLUSIONS: Primary meningococcal pericarditis is a remarkably unusual presentation of meningococcal disease. Rapid progression to tamponade physiology can develop in these patients and monitoring for signs of pericarditis in patients with meningococcal disease should be implemented. Reference #1: Pericarditis as a complication of meningococcal meningitis. Morse JR, Oretsky MI, Hudson JA, Ann Intern Med. 1971;74(2):212. Reference #2: Update on meningococcal disease with emphasis on pathogenesis and clinical management. van Deuren M, Brandtzaeg P, van der Meer JW. Clin Microbiol Rev. 2000 Jan; 13(1):144-66. Reference #3: Zeidan A, Tariq S, Faltas B, Urban M, McGrody K. A case of primary meningococcal pericarditis caused by Neisseria meningitidis serotype Y with rapid evolution into cardiac tamponade. J Gen Intern Med. 2008;23(9):1532–1535. DISCLOSURES: No relevant relationships by Giovi Grasso-Knight, source=Web Response No relevant relationships by Matthew Schloop, source=Web Response No relevant relationships by Mouhamed Shatila, source=Web Response

DVT, PULMONARY EMBOLISM, AND PARADOXICAL EMBOLISM THANKS TO A CARDIAC CONNECTION

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Concomitant venous and arterial thrombi are usually seen in hypercoagulable states, but we present an unusual case where a patient developed paradoxical embolism of deep venous thrombosis (DVT) and pulmonary embolism (PE) leading to acute limb ischemia due to the presence of a patent foramen ovale (PFO). CASE PRESENTATION: 70-year-old female with history of OSA, hypertension, diabetes on insulin presented to the hospital with sudden onset right lower extremity pain, numbness and weakness of few hours. Patient also complained of dyspnea on exertion that started about 3 weeks prior. At presentation, patient was hypoxic, and examination demonstrated a right lower extremity that was cold to touch and numb with faint dorsalis pedis and posterior tibialis pulses on the right compared to the left. CT chest, abdomen, pelvis with contrast showed an acute extensive pulmonary emboli with right heart strain, acute thrombus at the origin of the celiac trunk, superior and inferior mesenteric arteries, left lower pole renal artery, right common femoral artery, and left internal iliac artery with occlusion of the right common femoral, left internal iliac, and left lower pole renal arteries. Lower extremity venous doppler showed an acute deep venous thrombosis of the left popliteal vein and the femoral vein in the lower thigh. 2D echo with bubble study revealed D-shaped left ventricle due to septal flattening, consistent with elevated right ventricular pressure atrial septal aneurysm and a patent foramen ovale. Patient was started on heparin drip and emergently taken to the operating room for right lower extremity thrombo-embolectomy of right iliac, right femoral, right profunda, right superficial femoral artery, right popliteal artery and 4 compartment fasciotomies. Post-operatively, anticoagulation was changed to Rivaroxaban and was discharged to acute inpatient rehab in stable condition. DISCUSSION: The prevalence of PFO in the general population is more than 25% but most are asymptomatic, the prevalence of DVT was found to be as high as 41% in one study of patients with suspected paradoxical embolism and concomitant patent foramen ovale. Most of the data about PFO closure are for prevention of recurrent cryptogenic stroke with paucity of data on how to manage PFO and paradoxical embolism causing limb ischemia with associated DVT and PE. CONCLUSIONS: A high index of suspicion for PFO should be maintained when a patient with PE and/or DVT presents with concomitant evidence of arterial thromboembolism. Reference #1: 1.Stollberger C, Slany J, Schuster I, Leitner H, Winkler W, Karnik R. The Prevalence of Deep Venous Thrombosis in Patients with Suspected Paradoxical Embolism. Ann Intern Med. 1993;119:461–465. doi: 10.7326/0003-4819-119-6-199309150-00003 Reference #2: 2.Homma, S. and R. L. Sacco (2005). "Patent foramen ovale and stroke.” Circulation 112(7): 1063-1072. DISCLOSURES: No relevant relationships by Nellowe Candelario, source=Web Response No relevant relationships by Adegbola Oluwole, source=Web Response

Palliative, Hospice, and End-of-Life Care and OBRA Regulations

Palliative, Hospice, and End-of-Life Care and OBRA Regulations

THE ENIGMATIC CASE OF RECURRENT VENTILATORY DEPENDENT RESPIRATORY FAILURE

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Amiodarone, one of the most frequently prescribed antiarrhythmic medications in the United States, is associated with serious side effects including amiodarone-induced pulmonary toxicity (APT). One needs high suspicion to diagnose APT as the presentation can be misdiagnosed as pneumonia and heart failure. CASE PRESENTATION: A 74-year-old Caucasian female presented to the emergency department with progressively worsening shortness of breath and dry cough. She had a past medical history of left ventricular diastolic dysfunction, atrial fibrillation (on amiodarone 200mg/day), rheumatoid arthritis (RA), and 2 prior episodes of ventilatory dependent respiratory failure. On examination, the patient was hypoxemic on room air and had bibasilar lung crackles. BNP was elevated and Chest x-ray showed vascular congestion and perihilar infiltrates. The patient was placed on BiPAP for respiratory support and admitted to CCU for acute hypoxic respiratory failure secondary to CHF exacerbation. Diuretics did not improve the patient's condition and subsequent infectious workup was negative. CT chest showed patchy air-space consolidation and ground-glass opacities. Upon further interrogation, it was found that she was started on amiodarone 4 years back and multiple intubations for respiratory failure reported within the previous 2 years which responded to steroids. Amiodarone-induced pulmonary toxicity was diagnosed based on surgical lung biopsy revealing vacuolated foamy macrophages in alveolar pneumocytes, bronchial epithelial cells, and endothelial cells with diffuse interstitial pneumonitis and fibrosis. Amiodarone was discontinued and steroids were started at 1 mg/kg with a slow taper. The patient was subsequently extubated. DISCUSSION: Though APT can occur at any time after treatment is initiated, patients on a daily dose of 400 mg for >2 months or 200 mg daily for >2 years are at high risk. The reported incidence rate varies from 1.6 to 15% for daily doses of 400mg or less. The risk factors include > 60 years, high levels of des-ethyl metabolite, pre-existing lung disease, history of cardiothoracic surgery, use of iodinated contrast media, and/or use of high oxygen mixtures. Pathophysiology is direct cytotoxicity due to reactive oxygen species and the angiotensin enzyme system activation. In this patient, the diagnosis was delayed because the respiratory decompensation was attributed to heart failure. Despite adequate diuresis with central venous pressure of 6 cm H20 and negative infectious workup, her respiratory symptoms did not resolve. We were able to pinpoint the culprit behind her respiratory failure with a surgical lung biopsy and a history of amiodarone exposure. CONCLUSIONS: Strong index of suspicion for APT is necessary for prompt diagnosis in patients receiving amiodarone and presenting with respiratory symptoms. Reference #1: Schwaiblmair M, Berghaus T, Haeckel T, Wagner T, Von Scheidt W. Amiodarone-induced pulmonary toxicity: an under-recognizedand severe adverse effects?.Clin Res Cardiol 2010; 99:693–700 Reference #2: Kitaichi M. Differential diagnosis of bronchiolitis obliterans organizing pneumonia. Chest 1992; 102 (suppl.):44S-49S Reference #3: Marchlinski FE, Gansler TS, Waxman HL, Josephson ME. Amiodarone pulmonary toxicity. Ann Intern Med 1982; 97: 839-845. DISCLOSURES: No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Mashrutee Maharaul, source=Web Response No relevant relationships by SHREY SHAH, source=Web Response No relevant relationships by ARCHANA SREEKANTAN NAIR, source=Web Response

Recruitment Strategy for Potential COVID-19 Convalescent Plasma Donors

Recruitment Strategy for Potential COVID-19 Convalescent Plasma Donors

Orthopaedic Randomized Controlled Trials Published in General Medical Journals Are Associated With Higher Altmetric Attention Scores and Social Media Attention Than Nonorthopaedic Randomized Controlled Trials

To (1) compare the Altmetric Attention Score (AAS) and citation rates between orthopaedic and nonorthopaedic randomized controlled trials (RCTs) from 5 high-impact medical journals and (2) identify general characteristics of these articles associated with greater exposure on social media platforms. Articles published in The New England Journal of Medicine (NEJM), Lancet, The Journal of the American Medical Association (JAMA), Annals of Internal Medicine, and Archives of Internal Medicine between January 2011 and December 2016 were analyzed. These journals were selected based on retaining high impact factors with rigorous publication standards and availability of the AAS for their publications. The queried time frame was chosen to balance the inception of the AAS with an optimal period for citation accrual. A total of 14 article characteristics, in addition to number of Tweets, Facebook shares, news mentions, and the AAS, were extracted. Inclusion criteria were orthopaedic RCTs reporting on outcomes after surgical intervention. Linear regression was used to assess the relationship between publication characteristics and the AAS and social media attention. A total of 9 orthopaedic and 59 nonorthopaedic RCTs were included. The mean AASs were significantly different (574 ± 565.7 versus 256.9 ± 222.3, P= .003), whereas citation rate was not (192.2 ± 117.1 versus 382.3 ± 560.3, P= .317). Orthopaedic RCTs had a significantly greater number of mentions on Twitter and Facebook (P < .001). A higher AAS significantly associated with a greater number of citations (β= 0.75, P= .019) for orthopaedic RCTs. The mean AAS of orthopaedic RCTs favoring nonoperative management (809.6 ± 676.3) was greater than those favoring operative treatment (292.0 ± 248.9) but was not statistically significant (P=.361). Orthopaedic RCTs published in 5 high-impact general medical journals had a significantly greater mean AAS relative to nonorthopaedic RCTs, with no differences in citation rates. Additionally, there was a strong association between the AAS and citation rate of orthopaedic RCTs. Orthopaedic RCTs had greater social media exposure on both Twitter and Facebook. Orthopaedic surgeons, researchers, and providers who publish RCTs in high-impact medical journals can anticipate extensive social media attention for their articles relative to other nonorthopaedic RCTs in the same journals. Social media attention may be related to operative versus nonoperative management topics. This study provides further evidence for the increasing use of the AAS and its association with citation accrual.

Azithromycin for severe COVID-19

Azithromycin for severe COVID-19

Web Exclusive. Annals On Call - Regulatory T Cells: Treatment for COVID-19?

Web Exclusives1 September 2020Annals On Call - Regulatory T Cells: Treatment for COVID-19?FREERobert M. Centor, MD and Franco R. D’Alessio, MDRobert M. Centor, MDHuntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)Search for more papers by this author and Franco R. D’Alessio, MDJohns Hopkins University School of Medicine, Baltimore, Maryland (F.R.D.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/A19-0037 CME/MOC SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In this episode of Annals On Call, Dr. Centor discusses the potential use of regulatory T cells to treat patients with acute respiratory distress syndrome associated with COVID-19 with Dr. Franco R. D’Alessio.Annals articles discussed include...Regulatory T Cells for Treating Patients With COVID-19 and Acute Respiratory Distress Syndrome: Two Case Reports: https://www.acpjournals.org/doi/10.7326/L20-0681About Annals On CallAnnals 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. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Huntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)Johns Hopkins University School of Medicine, Baltimore, Maryland (F.R.D.)Disclosures: Dr. Centor has disclosed the following: Consultancy: DynaMed, MDCalc, Medscape, National Kidney Foundation, The Curbsiders. Employment: U.S. Department of Veterans Affairs. Dr. D’Alessio has disclosed the following: Employment: Johns Hopkins University School of Medicine. Research grants/contracts: NHLBI R01 HL131812. Patent owner: Patent C13113_P13113-04—U.S. patent application no. 15/542,380 Compositions and Methods to Accelerate Resolution of Acute Lung Inflammation pending.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoRegulatory T Cells for Treating Patients With COVID-19 and Acute Respiratory Distress Syndrome: Two Case Reports Douglas E. Gladstone , Bo Soo Kim , Kathy Mooney , Andrew H. Karaba , and Franco R. D'Alessio Metrics 1 September 2020Volume 173, Issue 5Page: OC1KeywordsAcute respiratory distress syndromeCOVID-19DisclosureHealth careKidneysPatientsPneumoniaResearch grantsRespiratory system proceduresT cells ePublished: 1 September 2020 Issue Published: 1 September 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...

Annals for Educators - 1 September 2020.

Annals for Educators - 1 September 2020.

Mavacamten: treatment aspirations in hypertrophic cardiomyopathy

Managing dynamic left ventricular outflow tract (LVOT) obstruction remains one of the most challenging therapeutic aspects of hypertrophic cardiomyopathy. Individuals who are affected frequently present with disabling symptoms, which can be ameliorated following reduction of LVOT obstruction. Pharmacological treatment currently comprises non-disease specific therapies such as β blockers, negatively inotropic calcium channel blockers, and disopyramide, which offer a variable degree of symptomatic relief and are often limited by side-effects. 1 Ammirati E Contri R Coppini R Cecchi F Frigerio M Olivotto I Pharmacological treatment of hypertrophic cardiomyopathy: current practice and novel perspectives. Eur J Heart Fail. 2016; 18: 1106-1118 Crossref PubMed Scopus (57) Google Scholar Enhanced myocardial contractility is a key factor in the pathophysiology of LVOT obstruction. 2 Anderson RL Trivedi DV Sarkar SS et al. Deciphering the super relaxed state of human β-cardiac myosin and the mode of action of mavacamten from myosin molecules to muscle fibers. Proc Natl Acad Sci USA. 2018; 115: e8143-e8152 Crossref PubMed Scopus (93) Google Scholar Mavacamten is a first-in-class, selective allosteric inhibitor of cardiac myosin ATPase, which reduces actin-myosin cross-bridge formation, thereby reducing myocardial contractility and improving myocardial energetics. 3 Rohde JA Roopnarine O Thomas DD Muretta JM Mavacamten stabilizes an autoinhibited state of two-headed cardiac myosin. Proc Natl Acad Sci USA. 2018; 115: e7486-e7494 Crossref PubMed Google Scholar Animal studies showed that mavacamten reduced myocardial contraction in a dose-dependent manner and relieved LVOT obstruction. 4 Stern JA Markova S Ueda Y et al. A small molecule inhibitor of sarcomere contractility acutely relieves left ventricular outflow tract obstruction in feline hypertrophic cardiomyopathy. PLoS One. 2016; 11e0168407 Crossref PubMed Scopus (46) Google Scholar These findings were replicated in a phase 2 trial (PIONEER-HCM), in which mavacamten reduced the post-exercise LVOT gradient, increased peak oxygen consumption (pVO2), and improved symptoms in patients with the condition. 5 Heitner SB Jacoby D Lester SJ et al. Mavacamten treatment for obstructive hypertrophic cardiomyopathy: a clinical trial. Ann Intern Med. 2019; 170: 741-748 Crossref PubMed Scopus (67) Google Scholar Mavacamten for treatment of symptomatic obstructive hypertrophic cardiomyopathy (EXPLORER-HCM): a randomised, double-blind, placebo-controlled, phase 3 trialTreatment with mavacamten improved exercise capacity, LVOT obstruction, NYHA functional class, and health status in patients with obstructive hypertrophic cardiomyopathy. The results of this pivotal trial highlight the benefits of disease-specific treatment for this condition. Full-Text PDF

All Women Should be Screened for Anxiety, Federal Panel Says

Back to table of contents Previous article Next article Clinical & ResearchFull AccessAll Women Should be Screened for Anxiety, Federal Panel SaysKatie O'ConnorKatie O'ConnorSearch for more papers by this authorPublished Online:13 Aug 2020https://doi.org/10.1176/appi.pn.2020.7b6AbstractAPA was integral to the Women’s Preventive Services Initiative’s first recommendation for universal screening for anxiety, which applies to women and girls over age 13.All women and girls over 13 years old should be screened for anxiety, according to the Women’s Preventive Services Initiative (WPSI), a federal panel tasked with developing recommendations for the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services.The recommendation was published June 9 in the Annals of Internal Medicine. This is the first recommendation related to universal screening for anxiety that WPSI has issued.The recommendation that all women and girls over 13 receive anxiety screenings will draw attention to a condition that is often underdiagnosed and undertreated, says APA CEO and Medical Director Saul Levin, M.D., M.P.A.“Anxiety disorders are some of the most prevalent and consequential mental health problems among women in the United States,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a news release. “This groundbreaking recommendation will be a critical step in the advancement of the diagnosis and treatment of these conditions, which have previously been underdiagnosed and undertreated.”Maureen Sayres Van Niel, M.D., the APA Assembly’s representative to the Caucus of Women Psychiatrists and chair of the Assembly Committee of Representatives of Minority/Underrepresented Groups, was a member of the WPSI Steering Committee and an author of the clinical guidelines published in the Annals of Internal Medicine. She was the first mental health practitioner to be appointed to the panel in 2016 (see Psychiatric News).“This recommendation was a direct result of a collaboration between APA and other major medical associations throughout the country to develop an integrated plan to screen women for mental health problems as well as physical problems during their yearly well-woman visits,” Van Niel said. “The recommendation was approved for services without a copay to allow women of all socioeconomic groups to have equal access to this screening.”The Affordable Care Act requires that some preventive services must be covered without cost sharing, including copays, deductibles, and coinsurance. WPSI, which is led by the American College of Obstetricians and Gynecologists (ACOG), is responsible for recommending which women’s preventive services should be covered.The new recommendation applies to all adolescent and adult women 13 years or older, including pregnant and postpartum women. WPSI does not stipulate at what intervals screenings should occur and notes that clinicians should use their judgment when determining screening frequency.“Given the high prevalence of anxiety disorders, lack of recognition in clinical practice, and multiple problems associated with untreated anxiety, clinicians should consider screening women who have not been recently screened,” the recommendation states.Given recent events, it is especially important that women are screened for anxiety disorders now, Van Niel said. “This is a time when we are all experiencing national trauma. Anxiety levels, especially in women, have been shown to have increased due to the COVID-19 pandemic,” she said. “Additionally, the severe anxiety caused by structural racism is very significant, and it is especially evident right now.”She continued, “The U.S. Preventive Services Task Force recommends yearly screening for depression in all adults and adolescents and adding this universal screening for anxiety in women can be performed easily at the same time. The screening of men for anxiety disorders should also be addressed.”WPSI’s recommendation is especially important because the incidence of anxiety and depressive disorders in women is twice that of men, Van Niel pointed out. This increased incidence may be due to ongoing stresses women face, including carrying more of the household and childrearing responsibilities, experiencing a higher incidence of childhood and adult sexual abuse, and continued financial inequities due to a lack of paid leave and lower pay for equal work, she explained.“It is possible that, by correcting these social inequities, we can reduce the incidence of anxiety disorders in women,” she said.In an editorial accompanying the guidelines’ publication in the Annals of Internal Medicine, Kim G. Smolderen, Ph.D., and Matthew M. Burg, Ph.D., of the Yale University School of Medicine, emphasized the need to understand why so many women across age groups are struggling with anxiety. “Tools like the WPSI screening recommendations directed toward vulnerable groups are great first steps, but only one of the many elements needed to address mental health crises,” the authors wrote. ■“Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women’s Preventive Services Initiative” is posted here.“Screening for Anxiety in Adolescent and Adult Women” is posted here.“Awareness for Anxiety in Women: A Great Start” is posted here. ISSUES NewArchived

Racial disparities in positive airway pressure therapy adherence among veterans with obstructive sleep apnea.

Black individuals are disproportionately affected by diabetes, cardiovascular disease, obesity, and OSA. Adherence to PAP therapy has been reported to be lower among black individuals. This study seeks to examine associations between black race and PAP adherence among veterans with OSA. This was a retrospective study. Veterans newly diagnosed with OSA at a single Department of Veterans Affairs sleep center who were prescribed a modem-enabled PAP device between January 2015 and November 2017 were enrolled. PAP adherence was defined as ≥ 4 hours nightly usage for at least 70% of nights measured at 30 days from PAP setup. We examined the relationship between race and adherence, controlling for sex, marital status, age, socioeconomic status, residual apnea-hypopnea index), and mask leak. Of 3013 patients identified with OSA, 2571 (85%) were newly started on PAP therapy (95% male, aged 59 years ± 14 years, 45% married, 8% with neighborhood socioeconomic disadvantage). Twenty-five percent of participants were black, and 57% were white. PAP adherence at 30 days was 50% overall (42% among blacks, 53% among nonblacks). Black race was associated with reduced 30-day PAP adherence in unadjusted (P < .001) and adjusted logistic regression models (odds ratio = 0.64; 95% CI, 0.53 - 0.78; P < .001). Among veterans with OSA, black race was associated with reduced PAP adherence. These findings suggest health inequality among black individuals in the treatment of OSA.

Performance of creatinine- and cystatin C-based formulas to estimate glomerular filtration rate

Chronic kidney disease (CKD) affects 8-16% of the population worldwide and is a huge global health issue, given its strong association with higher cardiovascular morbidity and mortality, progression towards end-stage renal disease, and other complications including cognitive decline, mineral bone disease and anaemia [ [1] Gentile G. Remuzzi G. Novel biomarkers for renal diseases? None for the moment (but one). J Biomol Screen. 2016; 21: 655-670 Crossref PubMed Scopus (27) Google Scholar ]. Despite huge efforts to identify novel and more specific kidney biomarkers [ [2] Perico L. Perico N. Benigni A. The incessant search for renal biomarkers: is it really justified?. Curr Opin Nephrol Hypertens. 2019; 28: 195-202 Crossref PubMed Scopus (2) Google Scholar ], estimation of glomerular filtration rate (GFR) remains the mainstay of initial CKD diagnosis, its staging, and its subsequent management. Several international guidelines recommend the usage of different estimation formulas, including the 4- and 6-variable Modification of Diet in Renal Disease (MDRD) formulas [ [3] Levey A.S. Bosch J.P. Lewis J.B. Greene T. Rogers N. Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999; 130: 461-470 Crossref PubMed Scopus (12525) Google Scholar ] and, more recently, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, based on serum creatinine (CKD-EPIcrea) [ [4] Levey A.S. Stevens L.A. Schmid C.H. Zhang Y.L. Castro 3rd, A.F. Feldman H.I. et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009; 150: 604-612 Crossref PubMed Scopus (13708) Google Scholar ], cystatin C (CKD-EPIcys), or both (CKD-EPIcrea/cys), which are more reliable in people with estimated GFR higher than 60 mL/min/1.73 m2. In this issue of the Journal, the timely systematic review by Zou and colleagues provides original insights on the performance of GFR estimating equations. The analysis included 35 studies, relevant to primary care, with 23,667 adult participants, aimed to establish the bias, accuracy and precision of estimated GFR using the three CKD-EPI equations [ [5] Zou L.-X. Sun L. Nicholas S.B. Lu Y. K S.S. Hua R. Comparison of bias and accuracy using cystatin C and creatinine in CKD-EPI equations for GFR estimation. Eur J Inter Med. 2020; https://doi.org/10.1016/j.ejim.2020.04.044 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar ]. The mean bias was expressed as the difference between measured GFR and estimated GFR by the CKD-EPIcrea, CKD-EPIcys, and CKD-EPIcrea/cys formulas, in mL/min/1.73 m2. Accuracy was expressed as percentage of eGFR readings within 30% of measured GFR, or P30. Specifically, the Authors assessed the different accuracy of the three CKD-EPI formulas in people with measured GFR above or below 60 mL/min/1.73 m2, aged < 70 versus ≥ 70 years, or Asians versus non-Asians. Precision was assessed by the coefficient of correlation (R) between measured GFR and estimated GFR.

Web Exclusive. Annals On Call - Diagnosing SARS-CoV-2 Infection: Symptoms or No Symptoms?

Web Exclusives18 August 2020Annals On Call - Diagnosing SARS-CoV-2 Infection: Symptoms or No Symptoms?FREERobert M. Centor, MD and Jeanne Marrazzo, MD, MPHRobert M. Centor, MDHuntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)Search for more papers by this author and Jeanne Marrazzo, MD, MPHUniversity of Alabama at Birmingham School of Medicine, Birmingham, Alabama (J.M.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/A19-0036 CME/MOC SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In this episode of Annals On Call, Dr. Centor discusses challenges to diagnosing COVID-19 with Dr. Jeanne Marrazzo.Annals articles discussed include...Prevalence of Asymptomatic SARS-CoV-2 Infection. A Narrative Review: https://www.acpjournals.org/doi/10.7326/M20-3012Serodiagnostics for Severe Acute Respiratory Syndrome–Related Coronavirus-2. A Narrative Review: https://www.acpjournals.org/doi/10.7326/M20-2854About Annals On CallAnnals 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. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Huntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)University of Alabama at Birmingham School of Medicine, Birmingham, Alabama (J.M.)Disclosures: Dr. Centor has disclosed the following: Consultancy: DynaMed, MDCalc, Medscape, National Kidney Foundation, The Curbsiders. Employment: U.S. Department of Veterans Affairs. Dr. Marrazzo has disclosed no conflicts of interest.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.This article was published at Annals.org on 12 August 2020. Previousarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoPrevalence of Asymptomatic SARS-CoV-2 Infection Daniel P. Oran and Eric J. Topol Serodiagnostics for Severe Acute Respiratory Syndrome–Related Coronavirus 2 Matthew P. Cheng , Cedric P. Yansouni , Nicole E. Basta , Michaël Desjardins , Sanjat Kanjilal , Katryn Paquette , Chelsea Caya , Makeda Semret , Caroline Quach , Michael Libman , Laura Mazzola , Jilian A. Sacks , Sabine Dittrich , and Jesse Papenburg Metrics 18 August 2020Volume 173, Issue 4Page: OC1KeywordsCOVID-19Conflicts of interestDiagnostic techniquesDisclosureHealth careKidneysPatients ePublished: 12 August 2020 Issue Published: 18 August 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.Loading ...

The impact of inflammatory bowel disease on sexual health in men: A scoping review.

To review the literature on the impact of inflammatory bowel disease on the sexual health of men and make recommendations for nursing practice and research. Inflammatory bowel disease is a chronic condition of the gastrointestinal tract, causing symptoms that may impact upon sexual health. Specialist nurses are well positioned to assess and manage sexual health, but there is a lack of clinical guidance, especially in relation to men. A systematic scoping review following the Arksey and O'Malley (International Journal of Social Research Methodology, 8, 2005, 19) framework reported in line with the PRISMA-ScR checklist (Tricco et al., Annals of Internal Medicine, 169, 2018, 467). OVID MEDLINE ALL [R], OVID EMBASE [R], OVID PsychINFO, EBSCO CINAHL Complete, The Cochrane Library and ProQuest were searched. Inclusion and exclusion criteria were applied independently by two reviewers. Data were extracted, charted and summarised from eligible studies. Thirty-one studies met the inclusion criteria. These were synthesised under three categories: mediators, moderators and descriptors of sexual health. Depression, disease activity and surgery were the most commonly cited disease-related factors to affect sexual health in men. The most commonly used assessment tool was The International Index of Erectile Function. Descriptors of function included frequency of intercourse, libido and the ability to maintain a desired sexual role. The effect of inflammatory bowel disease on sexual health in men involves a complex interaction of physical and psychosocial factors. Researchers must explore areas outside of erectile function to understand how the disease impacts sexuality, sexual well-being and masculinity. This can be achieved through qualitative exploration of patient, partner and health professional experiences. A holistic nursing assessment of men with inflammatory bowel disease should include sexual health. Developing understanding of how the disease influences sexual interaction and expression will facilitate support that is relevant, accessible and of value to men living with the disease.

Uptake of core outcome sets by clinical trialists publishing in major medical journals: Protocol

Background: Outcome heterogeneity, selective reporting, and choosing outcomes that do not reflect needs and priorities of stakeholders, limit the examination of health intervention effects, particularly in late phase trials. Core outcome sets (COS) are a proposed solution to these issues. A COS is an agreed-upon, standardised set of outcomes that should be measured and reported as a minimum in all trials in a specific area of health or healthcare. COS are intended to increase standardisation of outcome measurement and reporting to better enable comparisons between, and synthesis of findings of trials in a particular health area. Methods: This study will examine late phase trials, published between October 2019 and March 2020 (inclusive), in the following five medical journals: New England Journal of Medicine, Journal of the American Medical Association, Lancet, BMJ, and Annals of Internal Medicine. Trials will be examined to determine if they refer to a COS, and whether they use a COS. Trialists for each identified trial will subsequently be contacted to complete an online survey examining trialists' awareness of, and decisions to search for and use a COS. Discussion: This study will provide important information on uptake of COS by later phase trialists in major medical journals, and the views of these trialists on COS use in trials. These findings will inform approaches to increasing awareness and uptake of COS in future health trials.

Chronic Obstructive Pulmonary Disease (Japanese Version).

In the Clinic4 August 2020Chronic Obstructive Pulmonary Disease (Japanese Version)Wassim W. Labaki, MD, MS and Sharon R. Rosenberg, MD, MSWassim W. Labaki, MD, MSUniversity of Michigan, Ann Arbor, Michigan (W.W.L.)Search for more papers by this author and Sharon R. Rosenberg, MD, MSNorthwestern University, Chicago, Illinois (S.R.R.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/IsTranslatedFrom_AITC202008040_Japanese SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Editors' Note: This article (available in PDF format) is the translated Japanese version of In the Clinic: Chronic Obstructive Pulmonary Disease (Labaki WW, Rosenberg SR. Chronic Obstructive Pulmonary Disease. Ann Intern Med. 2020;173:ITC17-ITC32. doi:10.7326/AITC202008040. Author, Article, and Disclosure InformationAuthors: Wassim W. Labaki, MD, MS; Sharon R. Rosenberg, MD, MSAffiliations: University of Michigan, Ann Arbor, Michigan (W.W.L.)Northwestern University, Chicago, Illinois (S.R.R.)Funding Source: American College of Physicians.Acknowledgment: The authors thank Michael R. Littner, MD, author of the previous version of this In the Clinic.Disclosures: Dr. Labaki, ACP Contributing Author, reports nonfinancial support from Pulmonx and personal fees from Konica Minolta outside the submitted work. Dr. Rosenberg, ACP Contributing Author, has nothing to disclose. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0505.With the assistance of additional physician writers, the editors of Annals of Internal Medicine develop In the Clinic using MKSAP and other resources of the American College of Physicians. The patient information page was written by Monica Lizarraga from the Patient and Interprofessional Partnership Initiative at the American College of Physicians.In the Clinic does not necessarily represent official ACP clinical policy. For ACP clinical guidelines, please go to https://www.acponline.org/clinical_information/guidelines/. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoChronic Obstructive Pulmonary Disease Wassim W. Labaki and Sharon R. Rosenberg Metrics 4 August 2020Volume 173, Issue 3Page: JITC17-JITC32KeywordsBronchodilatorsChronic obstructive pulmonary diseaseDyspneaEmphysemaExerciseForced expiratory volume in the first second of expirationLungsMortalityOxygenThorax ePublished: 16 May 2023 Issue Published: 4 August 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

COVID-19: An Opportunity to Reimagine Colorectal Cancer Diagnostic Testing—A New Paradigm Shift

ABSTRACT Colorectal cancer is the third leading cause of cancer related deaths and to date, the COVID-19 pandemic has led to major disruptions of the diagnosis and treatment pathways of this cancer, which may adversely affect survival outcomes for many years. Colorectal cancer pathways must be maintained at a near normal throughput with urgent attention to the backlog of patients to avoid a potential crisis of avoidable cancer deaths. A radical review and revamping of endoscopy services to improve efficiency during COVID-19 is urgently required. To date most endoscopy units have severely restricted their activity, except for time-critical diagnostic and therapeutic procedures. In the post- COVID-19 recovery phase, access to endoscopy services will increase but capacity will be reduced compared to before the pandemic, due to infection control measures. A pragmatic and safe strategy is urgently needed to clear the backlog of endoscopic procedures and for managing the new symptomatic referrals. We propose the use of non-invasive tests, such as FIT and mSEPT9 combined with “safety netting” to “rule out” colorectal cancer and to reduce the utilization of colonoscopy by up to 80% and limit the procedure to those patients at high risk of cancer.