<div><h4>Cardiovascular Health of Middle-Aged U.S. Adults by Income Level, 1999 to March 2020 : A Serial Cross-Sectional Study.</h4><i>Liu M, Aggarwal R, Zheng Z, Yeh RW, ... Joynt Maddox KE, Wadhera RK</i><br /><b>Background</b><br />Although cardiovascular mortality has increased among middle-aged U.S. adults since 2011, how the burden of cardiovascular risk factors has changed for this population by income level over the past 2 decades is unknown.<br /><b>Objective</b><br />To evaluate trends in the prevalence, treatment, and control of cardiovascular risk factors among low-income and higher-income middle-aged adults and how social determinants contribute to recent associations between income and cardiovascular health.<br /><b>Design</b><br />Serial cross-sectional study.<br /><b>Setting</b><br />NHANES (National Health and Nutrition Examination Survey), 1999 to March 2020.<br /><b>Participants</b><br />Middle-aged adults (aged 40 to 64 years).<br /><b>Measurements</b><br />Age-standardized prevalence of hypertension, diabetes, hyperlipidemia, obesity, and cigarette use; treatment rates for hypertension, diabetes, and hyperlipidemia; and rates of blood pressure, glycemic, and cholesterol control.<br /><b>Results</b><br />The study population included 20 761 middle-aged adults. The prevalence of hypertension, diabetes, and cigarette use was consistently higher among low-income adults between 1999 and March 2020. Low-income adults had an increase in hypertension over the study period (37.2% [95% CI, 33.5% to 40.9%] to 44.7% [CI, 39.8% to 49.5%]) but no changes in diabetes or obesity. In contrast, higher-income adults did not have a change in hypertension but had increases in diabetes (7.8% [CI, 5.0% to 10.6%] to 14.9% [CI, 12.4% to 17.3%]) and obesity (33.0% [CI, 26.7% to 39.4%] to 44.0% [CI, 40.2% to 47.7%]). Cigarette use was high and stagnant among low-income adults (33.2% [CI, 28.4% to 38.0%] to 33.9% [CI, 29.6% to 38.3%]) but decreased among their higher-income counterparts (18.6% [CI, 13.5% to 23.7%] to 11.5% [CI, 8.7% to 14.3%]). Treatment and control rates for hypertension were unchanged in both groups (>80%), whereas diabetes treatment rates improved only among the higher-income group (58.4% [CI, 44.4% to 72.5%] to 77.4% [CI, 67.6% to 87.1%]). Income-based disparities in hypertension, diabetes, and cigarette use persisted in more recent years even after adjustment for insurance coverage, health care access, and food insecurity.<br /><b>Limitation</b><br />Sample size limitations could preclude detection of small changes in treatment and control rates.<br /><b>Conclusion</b><br />Over 2 decades in the United States, hypertension increased in low-income middle-aged adults, whereas diabetes and obesity increased in their higher-income counterparts. Income-based disparities in hypertension, diabetes, and smoking persisted even after adjustment for other social determinants of health.<br /><b>Primary funding source</b><br />National Institutes of Health.<br /><br /><br /><br /><small>Ann Intern Med: 20 Nov 2023; epub ahead of print</small></div>

<div><h4>SARS-CoV-2 Virologic Rebound With Nirmatrelvir-Ritonavir Therapy : An Observational Study.</h4><i>Edelstein GE, Boucau J, Uddin R, Marino C, ... Li JZ, Siedner MJ</i><br /><b>Background</b><br />Data are conflicting regarding an association between treatment of acute COVID-19 with nirmatrelvir-ritonavir (N-R) and virologic rebound (VR).<br /><b>Objective</b><br />To compare the frequency of VR in patients with and without N-R treatment for acute COVID-19.<br /><b>Design</b><br />Observational cohort study.<br /><b>Setting</b><br />Multicenter health care system in Boston, Massachusetts.<br /><b>Participants</b><br />Ambulatory adults with acute COVID-19 with and without use of N-R.<br /><b>Intervention</b><br />Receipt of 5 days of N-R treatment versus no COVID-19 therapy.<br /><b>Measurements</b><br />The primary outcome was VR, defined as either a positive SARS-CoV-2 viral culture result after a prior negative result or 2 consecutive viral loads above 4.0 log<sub>10</sub> copies/mL that were also at least 1.0 log<sub>10</sub> copies/mL higher than a prior viral load below 4.0 log<sub>10</sub> copies/mL.<br /><b>Results</b><br />Compared with untreated persons (<i>n</i> = 55), those taking N-R (<i>n</i> = 72) were older, received more COVID-19 vaccinations, and more commonly had immunosuppression. Fifteen participants (20.8%) taking N-R had VR versus 1 (1.8%) who was untreated (absolute difference, 19.0 percentage points [95% CI, 9.0 to 29.0 percentage points]; <i>P</i> = 0.001). All persons with VR had a positive viral culture result after a prior negative result. In multivariable models, only N-R use was associated with VR (adjusted odds ratio, 10.02 [CI, 1.13 to 88.74]; <i>P</i> = 0.038). Virologic rebound was more common among those who started therapy within 2 days of symptom onset (26.3%) than among those who started 2 or more days after symptom onset (0%) (<i>P</i> = 0.030). Among participants receiving N-R, those who had VR had prolonged shedding of replication-competent virus compared with those who did not have VR (median, 14 vs. 3 days). Eight of 16 participants (50% [CI, 25% to 75%]) with VR also reported symptom rebound; 2 were completely asymptomatic. No post-VR resistance mutations were detected.<br /><b>Limitations</b><br />Observational study design with differences between the treated and untreated groups; positive viral culture result was used as a surrogate marker for risk for ongoing viral transmission.<br /><b>Conclusion</b><br />Virologic rebound occurred in approximately 1 in 5 people taking N-R, often without symptom rebound, and was associated with shedding of replication-competent virus.<br /><b>Primary funding source</b><br />National Institutes of Health.<br /><br /><br /><br /><small>Ann Intern Med: 13 Nov 2023; epub ahead of print</small></div>

<div><h4>Efficacy of Acupuncture for Chronic Spontaneous Urticaria : A Randomized Controlled Trial.</h4><i>Zheng H, Xiao XJ, Shi YZ, Zhang LX, ... Liang FR, Li Y</i><br /><b>Background</b><br />The effectiveness of acupuncture for patients with chronic spontaneous urticaria (CSU), reported in a few small-scale studies, is not convincing.<br /><b>Objective</b><br />To investigate whether acupuncture leads to better effects on CSU than sham acupuncture or waitlist control.<br /><b>Design</b><br />A multicenter, randomized, sham-controlled trial. (Chinese Clinical Trial Registry: ChiCTR1900022994).<br /><b>Setting</b><br />Three teaching hospitals in China from 27 May 2019 to 30 July 2022.<br /><b>Participants</b><br />330 participants diagnosed with CSU.<br /><b>Intervention</b><br />Participants were randomly assigned in a 1:1:1 ratio to receive acupuncture, sham acupuncture, or waitlist control over an 8-week study period (4 weeks for treatment and another 4 weeks for follow-up).<br /><b>Measurements</b><br />The primary outcome was the mean change from baseline in the Weekly Urticaria Activity Score (UAS7) at week 4. Secondary outcomes included itch severity scores, self-rated improvement, and Dermatology Life Quality Index scores.<br /><b>Results</b><br />The mean change in UAS7 (range, 0 to 42) for acupuncture from baseline (mean score, 23.5 [95% CI, 21.8 to 25.2]) to week 4 (mean score, 15.3 [CI, 13.6 to 16.9]) was -8.2 (CI, -9.9 to -6.6). The mean changes in UAS7 for sham acupuncture and waitlist control from baseline (mean scores, 21.9 [CI, 20.2 to 23.6] and 22.1 [CI, 20.4 to 23.8], respectively) to week 4 (mean scores, 17.8 [CI, 16.1 to 19.5] and 20.0 [CI, 18.3 to 21.6], respectively) were -4.1 (CI, -5.8 to -2.4) and -2.2 (CI, -3.8 to -0.5), respectively. The mean differences between acupuncture and sham acupuncture and waitlist control were -4.1 (CI, -6.5 to -1.8) and -6.1 (CI, -8.4 to -3.7), respectively, which did not meet the threshold for minimal clinically important difference. Fifteen participants (13.6%) in the acupuncture group and none in the other groups reported adverse events. Adverse events were mild or transient.<br /><b>Limitation</b><br />Lack of complete blinding, self-reported outcomes, limited generalizability because antihistamine use was disallowed, and short follow-up period.<br /><b>Conclusion</b><br />Compared with sham acupuncture and waitlist control, acupuncture produced a greater improvement in UAS7, although the difference from control was not clinically significant. Increased adverse events were mild or transient.<br /><b>Primary funding source</b><br />The National Key R&D Program of China and the Science and Technology Department of Sichuan Province.<br /><br /><br /><br /><small>Ann Intern Med: 13 Nov 2023; epub ahead of print</small></div>

<div><h4>In RA, use of systemic glucocorticoids ≥5 mg/d (prednisolone-equivalent) was linked to MACE at 8.7 y.</h4><i>Schattner A</i><br /><AbstractText>So H, Lam TO, Meng H, et al. <b>Time and dose-dependent effect of systemic glucocorticoids on major adverse cardiovascular event in patients with rheumatoid arthritis: a population-based study.</b> Ann Rheum Dis. 2023;82:1387-1393.37487608.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>In adults with BMI ≥27 kg/m and type 2 diabetes, adding tirzepatide to a lifestyle intervention increased weight loss at 72 wk.</h4><i>Davidson MB</i><br /><AbstractText>Garvey WT, Frias JP, Jastreboff AM, et al; SURMOUNT-2 investigators. <b>Tirzepatide once weekly for the treatment of obesity in people with type 2 diabetes (SURMOUNT-2): a double-blind, randomised, multicentre, placebo-controlled, phase 3 trial.</b> Lancet. 2023;402:613-626. 37385275.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>In ischemic LV dysfunction, adding PCI to medical therapy did not reduce a composite of death or aborted sudden death.</h4><i>Bach RG</i><br /><AbstractText><b>Perera D, Morgan HP, Ryan M, et al; REVIVED-BCIS2 Investigators.</b> Arrhythmia and death following percutaneous revascularization in ischemic left ventricular dysfunction: prespecified analyses from the REVIVED-BCIS2 trial. Circulation. 2023;148:862-871. 37555345.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>Relationship Between Clinician Language and the Success of Behavioral Weight Loss Interventions : A Mixed-Methods Cohort Study.</h4><i>Albury C, Webb H, Stokoe E, Ziebland S, ... Lee JJ, Aveyard P</i><br /><b>Background</b><br />International guidelines recommend that primary care clinicians recognize obesity and offer treatment opportunistically, but there is little evidence on how clinicians can discuss weight and offer treatment in ways that are well received and effective.<br /><b>Objective</b><br />To examine relationships between language used in the clinical visit and patient weight loss.<br /><b>Design</b><br />Mixed-methods cohort study.<br /><b>Setting</b><br />38 primary care clinics in England participating in the Brief Intervention for Weight Loss trial.<br /><b>Participants</b><br />246 patients with obesity seen by 87 general practitioners randomly sampled from the intervention group of the randomized clinical trial.<br /><b>Measurements</b><br />Conversation analysis of recorded discussions between 246 patients with obesity and 87 clinicians regarding referral to a 12-week behavioral weight management program offered as part of the randomized clinical trial. Clinicians\' interactional approaches were identified and their association with patient weight loss at 12 months (primary outcome) was examined. Secondary outcomes included patients\' agreement to attend weight management, attendance, loss of 5% body weight, actions taken to lose weight, and postvisit satisfaction.<br /><b>Results</b><br />Three interactional approaches were identified on the basis of clinicians\' linguistic and paralinguistic practices: creating a sense of referrals as \"good news\" related to the opportunity of the referral (<i>n</i> = 62); \"bad news,\" focusing on the harms of obesity (<i>n</i> = 82); or neutral (<i>n</i> = 102). Outcome data were missing from 57 participants, so weighted analyses were done to adjust for missingness. Relative to neutral news, good news was associated with increased agreement to attend the program (adjusted risk difference, 0.25 [95% CI, 0.15 to 0.35]), increased attendance (adjusted risk difference, 0.45 [CI, 0.34 to 0.56]), and weight change (adjusted difference, -3.60 [CI, -6.58 to -0.62]). There was no evidence of differences in mean weight change comparing bad and neutral news, and no evidence of differences in patient satisfaction across all 3 approaches.<br /><b>Limitations</b><br />Data were audio only, so body language and nonverbal cues could not be assessed. There is potential for selection bias and residual confounding.<br /><b>Conclusion</b><br />When raising the topic of excess weight in clinical visits, presenting weight loss treatment as a positive opportunity is associated with greater uptake of treatment and greater weight loss.<br /><b>Primary funding source</b><br />National Institute for Health and Care Research School for Primary Care Research and the Foundation for the Sociology of Health and Illness.<br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>In healthy older adults, low-dose aspirin did not differ from placebo for ischemic stroke but increased intracranial bleeding.</h4><i>Cruz-Flores S</i><br /><AbstractText>Cloud GC, Williamson JD, Thao LTP, et al. <b>Low-dose aspirin and the risk of stroke and intracerebral bleeding in healthy older people: secondary analysis of a randomized clinical trial.</b> JAMA Netw Open. 2023;6:e2325803. 37494038.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>The Mifepristone Litigation: Untangling the Implications of the Fifth Circuit\'s Decision for Abortion Access and the U.S. Food and Drug Administration.</h4><i>Zettler PJ, Grossman LA, Adashi EY, Cohen IG</i><br /><AbstractText>In August 2023, a federal appeals court issued an opinion in <i>Alliance for Hippocratic Medicine v FDA</i>, a case wherein a group of antiabortion medical organizations and physicians have challenged U.S. Food and Drug Administration (FDA) approval and regulation of mifepristone. This opinion contained some good news for the FDA, drug makers, and patients: the appeals court declined to halt the marketing of mifepristone altogether (as the trial court judge would have). But the court also decided that the FDA\'s 2016 and 2021 actions expanding the indication for mifepristone, lowering the drug\'s dose, and loosening restrictions on its distribution and use were likely unlawful, and it thus affirmed the trial court\'s order staying these actions. In this article, we explain key aspects of the opinion to health care professionals and consider the ways in which the appeals court\'s reasoning and conclusions, if followed by the Supreme Court, could undermine abortion access and public health going forward.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>In patients with type 2 diabetes or HF, SGLT2 inhibitors reduce gout-related outcomes.</h4><i>Nabrdalik K, Lip GYH</i><br /><AbstractText>Banerjee M, Pal R, Maisnam I, et al. <b>Serum uric acid lowering and effects of sodium-glucose cotransporter-2 inhibitors on gout: a meta-analysis and meta-regression of randomized controlled trials.</b> Diabetes Obes Metab. 2023;25:2697-2703. 37334516.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>Personal Actions to Create a Culture of Inclusion: Navigating Difficult Conversations With Medical Colleagues.</h4><i>Sulistio MS, Chen CL, Eleazu I, Godfrey S, Abraham RA, Toft LEB</i><br /><AbstractText>Microaggressions between members of a team occur often in medicine, even despite good intentions. Such situations call for difficult conversations that restore inclusivity, diversity, and a healthy work culture. These conversations are often hard because of the unique background, experiences, and biases of each person. In medicine, skillful navigation of these interactions is paramount as it influences patient care and the workplace culture. Although much has been published about difficult interactions between providers and patients, significantly less information is available to help navigate provider-to-provider interactions, despite their critical role in improving multidisciplinary patient care teams and organizational environments. This article is intended to serve as a guide for medical professionals who are interested in taking personal responsibility for promoting a safe and inclusive culture by engaging in and modeling difficult conversations with colleagues. The article outlines important considerations to assist with intentional preparation and modulation of responses for all parties involved: conversation initiators, observers of the incident, and conversation receivers. Although these interactions are challenging, together as medical professionals we can approach each other with humility and compassion to achieve our ultimate goal of promoting humanity, not only for our patients but for ourselves and one another.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>In low-risk penicillin allergies, direct oral challenge was noninferior to skin testing followed by oral challenge.</h4><i>Aung K, Htay T</i><br /><AbstractText>Copaescu AM, Vogrin S, James F, et al. <b>Efficacy of a clinical decision rule to enable direct oral challenge in patients with low-risk penicillin allergy: the PALACE randomized clinical trial.</b> JAMA Intern Med. 2023;183:944-952. 37459086.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>In severe, uncontrolled asthma, tezepelumab reduced exacerbations over 1 y regardless of type 2 inflammation level.</h4><i>Estrada RA, Maselli DJ</i><br /><AbstractText>Corren J, Menzies-Gow A, Chupp G, et al. <b>Efficacy of tezepelumab in severe, uncontrolled asthma: pooled analysis of the PATHWAY and NAVIGATOR clinical trials.</b> Am J Respir Crit Care Med. 2023;208:13-24. 37015033.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>Effects of Remote Patient Monitoring Use on Care Outcomes Among Medicare Patients With Hypertension : An Observational Study.</h4><i>Tang M, Nakamoto CH, Stern AD, Zubizarreta JR, ... Schwamm LH, Mehrotra A</i><br /><b>Background</b><br />Remote patient monitoring (RPM) is a promising tool for improving chronic disease management. Use of RPM for hypertension monitoring is growing rapidly, raising concerns about increased spending. However, the effects of RPM are still unclear.<br /><b>Objective</b><br />To estimate RPM\'s effect on hypertension care and spending.<br /><b>Design</b><br />Matched observational study emulating a longitudinal, cluster randomized trial. After matching, effect estimates were derived from a regression analysis comparing changes in outcomes from 2019 to 2021 for patients with hypertension at high-RPM practices versus those at matched control practices with little RPM use.<br /><b>Setting</b><br />Traditional Medicare.<br /><b>Patients</b><br />Patients with hypertension.<br /><b>Intervention</b><br />Receipt of care at a high-RPM practice.<br /><b>Measurements</b><br />Primary outcomes included hypertension medication use (medication fills, adherence, and unique medications received), outpatient visit use, testing and imaging use, hypertension-related acute care use, and total hypertension-related spending.<br /><b>Results</b><br />192 high-RPM practices (with 19 978 patients with hypertension) were matched to 942 low-RPM control practices (with 95 029 patients with hypertension). Compared with patients with hypertension at matched low-RPM practices, patients with hypertension at high-RPM practices had a 3.3% (95% CI, 1.9% to 4.8%) relative increase in hypertension medication fills, a 1.6% (CI, 0.7% to 2.5%) increase in days\' supply, and a 1.3% (CI, 0.2% to 2.4%) increase in unique medications received. Patients at high-RPM practices also had fewer hypertension-related acute care encounters (-9.3% [CI, -20.6% to 2.1%]) and reduced testing use (-5.9% [CI, -11.9% to 0.0%]). However, these patients also saw increases in primary care physician outpatient visits (7.2% [CI, -0.1% to 14.6%]) and a $274 [CI, $165 to $384]) increase in total hypertension-related spending.<br /><b>Limitation</b><br />Lacked blood pressure data; residual confounding.<br /><b>Conclusion</b><br />Patients in high-RPM practices had improved hypertension care outcomes but increased spending.<br /><b>Primary funding source</b><br />National Institute of Neurological Disorders and Stroke.<br /><br /><br /><br /><small>Ann Intern Med: 07 Nov 2023; epub ahead of print</small></div>

<div><h4>Impact of Clinical Demands on the Educational Mission in Hospital Medicine at 17 Academic Medical Centers : A Qualitative Analysis.</h4><i>Patel V, Keniston A, McBeth L, Arogyaswamy S, ... Mann S, Burden M</i><br /><b>Background</b><br />Clinical growth is outpacing the growth of traditional educational opportunities at academic medical centers (AMCs).<br /><b>Objective</b><br />To understand the impact of clinical growth on the educational mission for academic hospitalists.<br /><b>Design</b><br />Qualitative study using semistructured interviews that were analyzed using a mixed inductive and deductive method at the semantic level.<br /><b>Setting</b><br />Large AMCs across the United States that experienced clinical growth in the past 5 years.<br /><b>Participants</b><br />Division heads, section heads, and other hospital medicine (HM) leaders who oversaw and guided academic and clinical efforts of HM programs.<br /><b>Measurements</b><br />Themes and subthemes.<br /><b>Results</b><br />From September 2021 to January 2022, HM leaders from 17 AMCs participated in the interviews, and 3 key themes emerged. First, AMCs\' disproportionate clinical growth highlighted the tension between clinical and educational missions. This included a mismatch in supply and demand for traditional teaching time, competing priorities, and clinical growth being seen as both an opportunity and a threat. Second, amid the shifting landscape of high clinical demands and evolving educational opportunities, hospitalists still strongly prefer traditional teaching. To address this mismatch, HM groups have had to alter recruitment strategies and create innovative solutions to help build academic careers. Third, participants noted a need to reimagine the role and identity of an academic hospitalist, emphasizing tailored career pathways and educational roles spanning well beyond traditional house staff teaching teams.<br /><b>Limitation</b><br />The study focused on large AMCs.<br /><b>Conclusion</b><br />Although HM groups have implemented many creative strategies to address clinical growth and keep education front and center, challenges remain, particularly heavy clinical workloads and a continued dilution of traditional teaching opportunities.<br /><b>Primary funding source</b><br />Society of Hospital Medicine Student Scholar Grant.<br /><br /><br /><br /><small>Ann Intern Med: 31 Oct 2023; 176:1526-1535</small></div>

<div><h4>Breast Cancer Screening and Prevention.</h4><i>Farkas AH, Nattinger AB</i><br /><AbstractText>Breast cancer is the most common cancer among U.S. women and its incidence increases with age. Endogenous estrogen exposure, proliferative benign breast disease, breast density, and family history may also indicate increased risk for breast cancer. Early detection with screening mammography reduces breast cancer mortality, but the net benefits vary by age. Assessing a patient\'s individual breast cancer risk can guide decisions regarding breast cancer screening. All women benefit from healthy behaviors which may reduce breast cancer risk. Some women at increased risk for breast cancer may benefit from risk-reducing medications. Use of screening measures remains suboptimal, especially for uninsured women.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 31 Oct 2023; 176:ITC161-ITC176</small></div>

<div><h4>Health as a Human Right: A Position Paper From the American College of Physicians.</h4><i>DeCamp M, Snyder Sulmasy L, ACP Ethics, Professionalism and Human Rights Committee*</i><br /><AbstractText>The relationship of health to rights or human rights is complex. Although many find no right of any kind to health or health care, and others view health care as a right or human right, the American College of Physicians (ACP) instead sees <i>health</i> as a <i>human right</i>. The College, in the ACP Ethics Manual, has long noted the interrelated nature of health and human rights. Health as a human right also has implications for the social and structural determinants of health, including health care. Any rights framework is imperfect, and rights, human rights, and ethical obligations are not synonymous. Individual physicians and the profession have ethical obligations to patients, and these obligations can go beyond matters of rights. Society, too, has responsibilities-the equitable and universal access to appropriate health care is an ethical obligation of a just society. By recognizing health as a human right based in the intrinsic dignity and equality of all patients and supporting the patient-physician relationship and health systems that promote equitable access to appropriate health care, the United States can move closer to respecting, protecting, and fulfilling for all the opportunity for health.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 31 Oct 2023; epub ahead of print</small></div>

<div><h4>Clinical Effectiveness of Cognitively Enhanced Tai Ji Quan Training on Global Cognition and Dual-Task Performance During Walking in Older Adults With Mild Cognitive Impairment or Self-Reported Memory Concerns : A Randomized Controlled Trial.</h4><i>Li F, Harmer P, Eckstrom E, Fitzgerald K, Winters-Stone K</i><br /><b>Background</b><br />Mild cognitive impairment (MCI) negatively impacts cognition and dual-task abilities. A physical-cognitive integrated treatment approach could mitigate this risk for dementia.<br /><b>Objective</b><br />To compare the effectiveness of cognitively enhanced tai ji quan versus standard tai ji quan or stretching exercise in improving global cognition and reducing dual-task walking costs in older adults with MCI or self-reported memory concerns.<br /><b>Design</b><br />3-group, randomized (1:1:1), superiority trial. (ClinicalTrials.gov: NCT04070703).<br /><b>Setting</b><br />Community residential homes.<br /><b>Participants</b><br />318 older adults with self-reported memory decline or concern and a Clinical Dementia Rating (CDR) global score of 0.5 or lower at baseline.<br /><b>Intervention</b><br />Cognitively enhanced tai ji quan (<i>n</i> = 105), standard tai ji quan (<i>n</i> = 107), or stretching (<i>n</i> = 106). All groups exercised at home via real-time videoconferencing, 1 hour semiweekly for 24 weeks.<br /><b>Measurements</b><br />The co-primary endpoints were change in Montreal Cognitive Assessment (MoCA; range, 0 to 30) and dual-task walking costs (difference between single- and dual-task gait speed, expressed in percentage) from baseline to 24 weeks. Secondary outcomes included CDR-Sum of Boxes (CDR-SB), Trail Making Test B, Digit Span Backward (DSB), and physical performance tests. Outcomes were assessed at 16, 24 (primary endpoint), and 48 weeks (6 months after intervention).<br /><b>Results</b><br />A total of 304 participants (96%) completed the 24-week assessment. Cognitively enhanced tai ji quan outperformed standard tai ji quan and stretching with a greater improvement in MoCA score (mean difference, 1.5 points [98.75% CI, 0.7 to 2.2 points] and 2.8 points [CI, 2.1 to 3.6 points], respectively) and in dual-task walking (mean difference, 9.9% [CI, 2.8% to 16.6%] and 22% [CI, 13% to 31%], respectively). The intervention effects persisted at 48-week follow-up.<br /><b>Limitation</b><br />There was no nonexercise control group; participants had subjective or mild cognitive impairment.<br /><b>Conclusion</b><br />Among community-dwelling older adults with MCI, cognitively enriched tai ji quan therapy was superior to standard tai ji quan and stretching exercise in improving global cognition and reducing dual-task gait interference, with outcomes sustained at 48 weeks.<br /><b>Primary funding source</b><br />National Institute on Aging.<br /><br /><br /><br /><small>Ann Intern Med: 31 Oct 2023; epub ahead of print</small></div>

<div><h4>Effect of Complementary Interventions to Redesign Care on Teamwork and Quality for Hospitalized Medical Patients : A Pragmatic Controlled Trial.</h4><i>O\'Leary KJ, Johnson JK, Williams MV, Estrella R, ... Lee J, Manojlovich M</i><br /><b>Background</b><br />Multiple challenges impede interprofessional teamwork and the provision of high-quality care to hospitalized patients.<br /><b>Objective</b><br />To evaluate the effect of interventions to redesign hospital care delivery on teamwork and patient outcomes.<br /><b>Design</b><br />Pragmatic controlled trial. Hospitals selected 1 unit for implementation of interventions and a second to serve as a control. (ClinicalTrials.gov: NCT03745677).<br /><b>Setting</b><br />Medical units at 4 U.S. hospitals.<br /><b>Participants</b><br />Health care professionals and hospitalized medical patients.<br /><b>Intervention</b><br />Mentored implementation of unit-based physician teams, unit nurse-physician coleadership, enhanced interprofessional rounds, unit-level performance reports, and patient engagement activities.<br /><b>Measurements</b><br />Primary outcomes were teamwork climate among health care professionals and adverse events experienced by patients. Secondary outcomes were length of stay (LOS), 30-day readmissions, and patient experience. Difference-in-differences (DID) analyses of patient outcomes compared intervention versus control units before and after implementation of interventions.<br /><b>Results</b><br />Among 155 professionals who completed pre- and postintervention surveys, the median teamwork climate score was higher after than before the intervention only for nurses (<i>n</i> = 77) (median score, 88.0 [IQR, 77.0 to 91.0] vs. 80.0 [IQR, 70.0 to 89.0]; <i>P</i> = 0.022). Among 3773 patients, a greater percentage had at least 1 adverse event after compared with before the intervention on control units (change, 1.61 percentage points [95% CI, 0.01 to 3.22 percentage points]). A similar percentage of patients had at least 1 adverse event after compared with before the intervention on intervention units (change, 0.43 percentage point [CI, -1.25 to 2.12 percentage points]). A DID analysis of adverse events did not show a significant difference in change (adjusted DID, -0.92 percentage point [CI, -2.49 to 0.64 percentage point]; <i>P</i> = 0.25). Similarly, there were no differences in LOS, readmissions, or patient experience.<br /><b>Limitation</b><br />Adverse events occurred less frequently than anticipated, limiting statistical power.<br /><b>Conclusion</b><br />Despite improved teamwork climate among nurses, interventions to redesign care for hospitalized patients were not associated with improved patient outcomes.<br /><b>Primary funding source</b><br />Agency for Healthcare Research and Quality.<br /><br /><br /><br /><small>Ann Intern Med: 31 Oct 2023; epub ahead of print</small></div>

<div><h4>Effectiveness of Nirmatrelvir-Ritonavir Against the Development of Post-COVID-19 Conditions Among U.S. Veterans : A Target Trial Emulation.</h4><i>Ioannou GN, Berry K, Rajeevan N, Li Y, ... Huang GD, Bajema KL</i><br /><b>Background</b><br />COVID-19 has been linked to the development of many post-COVID-19 conditions (PCCs) after acute infection. Limited information is available on the effectiveness of oral antivirals used to treat acute COVID-19 in preventing the development of PCCs.<br /><b>Objective</b><br />To measure the effectiveness of outpatient treatment of COVID-19 with nirmatrelvir-ritonavir in preventing PCCs.<br /><b>Design</b><br />Retrospective target trial emulation study comparing matched cohorts receiving nirmatrelvir-ritonavir versus no treatment.<br /><b>Setting</b><br />Veterans Health Administration (VHA).<br /><b>Participants</b><br />Nonhospitalized veterans in VHA care who were at risk for severe COVID-19 and tested positive for SARS-CoV-2 during January through July 2022.<br /><b>Intervention</b><br />Nirmatrelvir-ritonavir treatment for acute COVID-19.<br /><b>Measurements</b><br />Cumulative incidence of 31 potential PCCs at 31 to 180 days after treatment or a matched index date, including cardiac, pulmonary, renal, thromboembolic, gastrointestinal, neurologic, mental health, musculoskeletal, endocrine, and general conditions and symptoms.<br /><b>Results</b><br />Eighty-six percent of the participants were male, with a median age of 66 years, and 17.5% were unvaccinated. Baseline characteristics were well balanced between participants treated with nirmatrelvir-ritonavir and matched untreated comparators. No differences were observed between participants treated with nirmatrelvir-ritonavir (<i>n</i> = 9593) and their matched untreated comparators in the incidence of most PCCs examined individually or grouped by organ system, except for lower combined risk for venous thromboembolism and pulmonary embolism (subhazard ratio, 0.65 [95% CI, 0.44 to 0.97]; cumulative incidence difference, -0.29 percentage points [CI, -0.52 to -0.05 percentage points]).<br /><b>Limitations</b><br />Ascertainment of PCCs using International Classification of Diseases, 10th Revision codes may be inaccurate. Evaluation of many outcomes could have resulted in spurious associations with combined thromboembolic events by chance.<br /><b>Conclusion</b><br />Out of 31 potential PCCs, only combined thromboembolic events seemed to be reduced by nirmatrelvir-ritonavir.<br /><b>Primary funding source</b><br />U.S. Department of Veterans Affairs.<br /><br /><br /><br /><small>Ann Intern Med: 31 Oct 2023; epub ahead of print</small></div>

<div><h4>Changes in Induced Medical and Procedural Abortion Rates in a Commercially Insured Population, 2018 to 2022 : An Interrupted Time-Series Analysis.</h4><i>Hwang CS, Kesselheim AS, Sarpatwari A, Huybrechts KF, Brill G, Rome BN</i><br /><b>Background</b><br />During the COVID-19 pandemic, access to in-person care was limited, and regulations requiring in-person dispensing of mifepristone for medical abortions were relaxed. The effect of the pandemic and accompanying regulatory changes on abortion use is unknown.<br /><b>Objective</b><br />To estimate changes in the incidence rate of induced medical and procedural abortions.<br /><b>Design</b><br />Serial cross-sectional study with interrupted time-series analyses.<br /><b>Setting</b><br />Commercially insured persons in the United States.<br /><b>Participants</b><br />Reproductive-aged women.<br /><b>Intervention</b><br />Onset of the COVID-19 pandemic in March 2020 and subsequent regulatory changes affecting the in-person dispensing requirement for mifepristone.<br /><b>Measurements</b><br />Monthly age-adjusted incidence rates of medical and procedural abortions were measured among women aged 15 to 44 years from January 2018 to June 2022. Medical abortions were classified as in-person or telehealth. Linear segmented time-series regression was used to calculate changes in abortion rates after March 2020.<br /><b>Results</b><br />In January 2018, the estimated age-adjusted monthly incidence rate of abortions was 151 per million women (95% CI, 142 to 161 per million women), with equal rates of medical and procedural abortions. After March 2020, there was an immediate 14% decrease in the monthly incidence rate of abortions (21 per million women [CI, 7 to 35 per million women]; <i>P</i> = 0.004), driven by a 31% decline in procedural abortions (22 per million women [CI, 16 to 28 per million women]; <i>P</i> < 0.001). Fewer than 4% of medical abortions each month were administered via telehealth.<br /><b>Limitation</b><br />Only abortions reimbursed by commercial insurance were measured.<br /><b>Conclusion</b><br />The incidence rate of procedural abortions declined during the COVID-19 pandemic, and this lower rate persisted after other elective procedures rebounded to prepandemic rates. Despite removal of the in-person dispensing requirement for mifepristone, the use of telehealth for insurance-covered medical abortions remained rare. Amid increasing state restrictions, commercial insurers have the opportunity to increase access to abortion care, particularly via telehealth.<br /><b>Primary funding source</b><br />Health Resources and Services Administration.<br /><br /><br /><br /><small>Ann Intern Med: 24 Oct 2023; epub ahead of print</small></div>

<div><h4>Inappropriate Prescribing to Older Patients by Nurse Practitioners and Primary Care Physicians.</h4><i>Huynh J, Alim SA, Chan DC, Studdert DM</i><br /><b>Background</b><br />Many U.S. states have legislated to allow nurse practitioners (NPs) to independently prescribe drugs. Critics contend that these moves will adversely affect quality of care.<br /><b>Objective</b><br />To compare rates of inappropriate prescribing among NPs and primary care physicians.<br /><b>Design</b><br />Rates of inappropriate prescribing were calculated and compared for 23 669 NPs and 50 060 primary care physicians who wrote prescriptions for 100 or more patients per year, with adjustment for practice experience, patient volume and risk, clinical setting, year, and state.<br /><b>Setting</b><br />29 states that had granted NPs prescriptive authority by 2019.<br /><b>Patients</b><br />Medicare Part D beneficiaries aged 65 years or older in 2013 to 2019.<br /><b>Measurements</b><br />Inappropriate prescriptions, defined as drugs that typically should not be prescribed for adults aged 65 years or older, according to the American Geriatrics Society\'s Beers Criteria.<br /><b>Results</b><br />Mean rates of inappropriate prescribing by NPs and primary care physicians were virtually identical (adjusted odds ratio, 0.99 [95% CI, 0.97 to 1.01]; crude rates, 1.63 vs. 1.69 per 100 prescriptions; adjusted rates, 1.66 vs. 1.68). However, NPs were overrepresented among clinicians with the highest and lowest rates of inappropriate prescribing. For both types of practitioners, discrepancies in inappropriate prescribing rates across states tended to be larger than discrepancies between these practitioners within states.<br /><b>Limitation</b><br />The Beers Criteria addresses the appropriateness of a selected subset of drugs and may not be valid in some clinical settings.<br /><b>Conclusion</b><br />Nurse practitioners were no more likely than physicians to prescribe inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians.<br /><b>Primary funding source</b><br />The Robert Wood Johnson Foundation and National Science Foundation.<br /><br /><br /><br /><small>Ann Intern Med: 24 Oct 2023; epub ahead of print</small></div>

<div><h4>COVID-19.</h4><i>Marks KM, Gulick RM</i><br /><AbstractText>COVID-19, the illness caused by SARS-CoV-2, became a worldwide pandemic in 2020. Initial clinical manifestations range from asymptomatic infection to mild upper respiratory illness but may progress to pulmonary involvement with hypoxemia and, in some cases, multiorgan involvement, shock, and death. Older adults, pregnant persons, those with common comorbidities, and those with immunosuppression are at greatest risk for progression. Vaccination is effective in preventing symptomatic infection and reducing risk for severe disease, hospitalization, and death. Antiviral treatment and immunomodulators have been shown to benefit certain patients. This article summarizes current recommendations on prevention, diagnosis, management, and treatment of COVID-19.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 10 Oct 2023; epub ahead of print</small></div>

<div><h4>Risk for Congenital Anomalies in Children Conceived With Medically Assisted Fertility Treatment : A Population-Based Cohort Study.</h4><i>Venetis C, Choi SKY, Jorm L, Zhang X, ... Norman RJ, Chambers GM</i><br /><b>Background</b><br />More than 2 million children are conceived annually using assisted reproductive technologies (ARTs), with a similar number conceived using ovulation induction and intrauterine insemination (OI/IUI). Previous studies suggest that ART-conceived children are at increased risk for congenital anomalies (CAs). However, the role of underlying infertility in this risk remains unclear, and ART clinical and laboratory practices have changed drastically over time, particularly there has been an increase in intracytoplasmic sperm injection (ICSI) and cryopreservation.<br /><b>Objective</b><br />To investigate the role of underlying infertility and fertility treatment on CA risks in the first 2 years of life.<br /><b>Design</b><br />Propensity score-weighted population-based cohort study.<br /><b>Setting</b><br />New South Wales, Australia.<br /><b>Participants</b><br />851 984 infants (828 099 singletons and 23 885 plural children) delivered between 2009 and 2017.<br /><b>Measurements</b><br />Adjusted risk difference (aRD) in CAs of infants conceived through fertility treatment compared with 2 naturally conceived (NC) control groups-those with and without a parental history of infertility (NC-infertile and NC-fertile).<br /><b>Results</b><br />The overall incidence of CAs was 459 per 10 000 singleton births and 757 per 10 000 plural births. Compared with NC-fertile singleton control infants (<i>n</i> = 747 018), ART-conceived singleton infants (<i>n</i> = 31 256) had an elevated risk for major genitourinary abnormalities (aRD, 19.0 cases per 10 000 births [95% CI, 2.3 to 35.6]); the risk remained unchanged (aRD, 22 cases per 10 000 births [CI, 4.6 to 39.4]) when compared with NC-infertile singleton control infants (<i>n</i> = 36 251) (that is, after accounting for parental infertility), indicating that ART remained an independent risk. After accounting for parental infertility, ICSI in couples without male infertility was associated with an increased risk for major genitourinary abnormalities (aRD, 47.8 cases per 10 000 singleton births [CI, 12.6 to 83.1]). There was some suggestion of increased risk for CAs after fresh embryo transfer, although estimates were imprecise and inconsistent. There were no increased risks for CAs among OI/IUI-conceived infants (<i>n</i> = 13 574).<br /><b>Limitations</b><br />This study measured the risk for CAs only in those children who were born at or after 20 weeks\' gestation. Observational study design precludes causal inference. Many estimates were imprecise.<br /><b>Conclusion</b><br />Patients should be counseled on the small increased risk for genitourinary abnormalities after ART, particularly after ICSI, which should be avoided in couples without problems of male infertility.<br /><b>Primary funding source</b><br />Australian National Health and Medical Research Council.<br /><br /><br /><br /><small>Ann Intern Med: 10 Oct 2023; epub ahead of print</small></div>

<div><h4>Xylazine Adulteration of the Heroin-Fentanyl Drug Supply : A Narrative Review.</h4><i>D\'Orazio J, Nelson L, Perrone J, Wightman R, Haroz R</i><br /><AbstractText>Xylazine is an animal sedative, approved by the U.S. Food and Drug Administration, that is commonly used in veterinary medicine and is not approved for human use. Since 2016, xylazine has consistently appeared in the illicitly manufactured fentanyl supply and has significantly increased in prevalence, likely due to its low cost, easy availability, and presumed synergistic psychoactive effect. Clinical experience along with the available pertinent research were used to review xylazine adulteration of the drug supply and provide guidance on the care of patients exposed to xylazine. This review discusses xylazine pharmacology, animal and human clinical effects, and what is known to date about care of patients experiencing acute overdose, xylazine-fentanyl withdrawal, and xylazine-associated wounds.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 10 Oct 2023; epub ahead of print</small></div>

<div><h4>Would You Screen This Patient for Cognitive Impairment? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.</h4><i>Burns RB, Barry MJ, Blacker D, Kanjee Z</i><br /><AbstractText>Dementia, according to the American Psychiatric Association\'s <i>Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition</i>, is defined by a significant decline in 1 or more cognitive domains that interferes with a person\'s independence in daily activities. Mild cognitive impairment (MCI) differs from dementia in that the impairment is not sufficient to interfere with independence. For the purposes of this discussion, cognitive impairment (CI) includes both dementia and MCI. Various screening tests are available for CI. These tests ask patients to perform a series of tasks that assess 1 or more domains of cognitive function or ask a caregiver to report on the patient\'s abilities. A positive result on a screening test does not equate to a diagnosis of CI; rather, it should lead to additional testing to confirm the diagnosis. On review of the evidence, the U.S. Preventive Services Task Force (USPSTF) concluded in 2020 that the evidence was insufficient to assess the balance of benefits and harms of screening for CI in older adults (\"I statement\"). The USPSTF did clarify that although there is insufficient evidence, there may be important reasons to identify CI. In this article, 2 experts review the available evidence to answer the following questions: What screening tools are available, and how effective are they in identifying patients with CI? What interventions are available for patients found to have CI, to what extent do they improve patient outcomes, and what, if any, negative effects occur? And, would they recommend screening for CI, and why or why not?</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 10 Oct 2023; epub ahead of print</small></div>

<div><h4>Implications of the Use of Artificial Intelligence Predictive Models in Health Care Settings : A Simulation Study.</h4><i>Vaid A, Sawant A, Suarez-Farinas M, Lee J, ... Singh K, Nadkarni GN</i><br /><b>Background</b><br />Substantial effort has been directed toward demonstrating uses of predictive models in health care. However, implementation of these models into clinical practice may influence patient outcomes, which in turn are captured in electronic health record data. As a result, deployed models may affect the predictive ability of current and future models.<br /><b>Objective</b><br />To estimate changes in predictive model performance with use through 3 common scenarios: model retraining, sequentially implementing 1 model after another, and intervening in response to a model when 2 are simultaneously implemented.<br /><b>Design</b><br />Simulation of model implementation and use in critical care settings at various levels of intervention effectiveness and clinician adherence. Models were either trained or retrained after simulated implementation.<br /><b>Setting</b><br />Admissions to the intensive care unit (ICU) at Mount Sinai Health System (New York, New York) and Beth Israel Deaconess Medical Center (Boston, Massachusetts).<br /><b>Patients</b><br />130 000 critical care admissions across both health systems.<br /><b>Intervention</b><br />Across 3 scenarios, interventions were simulated at varying levels of clinician adherence and effectiveness.<br /><b>Measurements</b><br />Statistical measures of performance, including threshold-independent (area under the curve) and threshold-dependent measures.<br /><b>Results</b><br />At fixed 90% sensitivity, in scenario 1 a mortality prediction model lost 9% to 39% specificity after retraining once and in scenario 2 a mortality prediction model lost 8% to 15% specificity when created after the implementation of an acute kidney injury (AKI) prediction model; in scenario 3, models for AKI and mortality prediction implemented simultaneously, each led to reduced effective accuracy of the other by 1% to 28%.<br /><b>Limitations</b><br />In real-world practice, the effectiveness of and adherence to model-based recommendations are rarely known in advance. Only binary classifiers for tabular ICU admissions data were simulated.<br /><b>Conclusion</b><br />In simulated ICU settings, a universally effective model-updating approach for maintaining model performance does not seem to exist. Model use may have to be recorded to maintain viability of predictive modeling.<br /><b>Primary funding source</b><br />National Center for Advancing Translational Sciences.<br /><br /><br /><br /><small>Ann Intern Med: 10 Oct 2023; epub ahead of print</small></div>

<div><h4>In adults, MRAs reduce AF occurrence vs. non-MRAs.</h4><i>Barnes GD</i><br /><AbstractText>Fatima K, Asad D, Shaikh N, et al. <b>A systematic review and meta-analysis on effectiveness of mineralocorticoid receptor antagonists in reducing the risk of atrial fibrillation.</b> Am J Cardiol. 2023;199:85-91. 37269781.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>In persistent dyspnea after COVID-19 ARDS, exercise training rehabilitation vs. usual PT reduced dyspnea at 90 d.</h4><i>Hill NS</i><br /><AbstractText>Romanet C, Wormser J, Fels A, et al. <b>Effectiveness of exercise training on the dyspnoea of individuals with long COVID: a randomised controlled multicentre trial.</b> Ann Phys Rehabil Med. 2023;66:101765. 37271020.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>In minor, nondisabling, acute ischemic stroke, DAPT was noninferior to IV alteplase for excellent functional outcome at 90 d.</h4><i>Eastin C</i><br /><AbstractText>Chen HS, Cui Y, Zhou ZH, et al; ARAMIS Investigators. <b>Dual antiplatelet therapy vs alteplase for patients with minor nondisabling acute ischemic stroke: the ARAMIS randomized clinical trial.</b> JAMA. 2023;329:2135-2144. 37367978.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Quality Indicators for Osteoporosis in Adults: A Review of Performance Measures by the American College of Physicians.</h4><i>Qaseem A, Mount CA, Campos K, McLean RM, ... Fitterman N, Performance Measurement Committee of the American College of Physicians*</i><br /><AbstractText>Primary osteoporosis is characterized by decreasing bone mass and density and reduced bone strength that leads to a higher risk for fracture, especially hip and spine fractures. The prevalence of osteoporosis in the United States is estimated at 12.6% for adults older than 50 years. Although it is most frequently diagnosed in White and Asian females, it still affects males and females of all ethnicities. Osteoporosis is considered a major health issue, which has prompted the development and use of several performance measures to assess and improve the effectiveness of screening, diagnosis, and treatment. These performance measures are often used in accountability, public reporting, and/or payment programs. However, the reliability, validity, evidence, attribution, and meaningfulness of performance measures have been questioned. The purpose of this paper is to present a review of current performance measures on osteoporosis and inform physicians, payers, and policymakers in their selection of performance measures for this condition. The Performance Measurement Committee identified 6 osteoporosis performance measures relevant to internal medicine physicians, only 1 of which was found valid at all levels of attribution. This paper also proposes a performance measure concept to address a performance gap for the initial approach to therapy for patients with a new diagnosis of osteoporosis based on the current American College of Physicians guideline.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>In T2DM uncontrolled with noninsulin glucose-lowering agents, weekly icodec reduced HbA vs. daily degludec at 26 wk.</h4><i>Belal H, Gandhi GY</i><br /><AbstractText>Lingvay I, Asong M, Desouza C, et al. <b>Once-weekly insulin icodec vs once-daily insulin degludec in adults with insulin-naive type 2 diabetes: the ONWARDS 3 randomized clinical trial.</b> JAMA. 2023;330:228-237. 37354562.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Association Between Vascular F-Fluorodeoxyglucose Uptake at Diagnosis and Change in Aortic Dimensions in Giant Cell Arteritis : A Cohort Study.</h4><i>Moreel L, Coudyzer W, Boeckxstaens L, Betrains A, ... Van Laere K, Blockmans D</i><br /><b>Background</b><br />Previous studies have shown that patients with giant cell arteritis (GCA) who have vascular <sup>18</sup>F-fluorodeoxyglucose (FDG) uptake at diagnosis are at increased risk for thoracic aortic complications.<br /><b>Objective</b><br />To measure the association between vascular FDG uptake at diagnosis and the change in aortic dimensions.<br /><b>Design</b><br />Prospective cohort study.<br /><b>Setting</b><br />University Hospitals Leuven.<br /><b>Patients</b><br />106 patients with GCA and FDG positron emission tomography (PET) imaging 3 days or less after initiation of glucocorticoids.<br /><b>Measurements</b><br />Patients had PET and computed tomography (CT) imaging at diagnosis and CT imaging yearly for a maximum of 10 years. The PET scans were scored 0 to 3 in 7 vascular areas and summed to a total vascular score (TVS). The PET scan results were positive when FDG uptake was grade 2 or greater in any large vessel. The association between vascular FDG uptake and aortic dimensions was estimated by linear mixed-effects models with random intercept and slope.<br /><b>Results</b><br />When compared with patients with a negative PET scan result, those with a positive scan result had a greater increase in the diameter of the ascending aorta (difference in 5-year progression, 1.58 mm [95% CI, 0.41 to 2.74 mm]), the diameter of the descending aorta (1.32 mm [CI, 0.38 to 2.26 mm]), and the volume of the thoracic aorta (20.5 cm³ [CI, 4.5 to 36.5 cm³]). These thoracic aortic dimensions were also positively associated with TVS. Patients with a positive PET scan result had a higher risk for thoracic aortic aneurysms (adjusted hazard ratio, 10.21 [CI, 1.25 to 83.3]).<br /><b>Limitation</b><br />The lengthy inclusion and follow-up period resulted in missing data and the use of different PET machines.<br /><b>Conclusion</b><br />Higher TVS was associated with greater yearly increase in thoracic aortic dimensions. Performing PET imaging at diagnosis may help to estimate the risk for aortic aneurysm formation.<br /><b>Primary funding source</b><br />None.<br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>In intermediate- or high-risk PE, catheter-directed thrombolysis is linked to reduced mortality vs. systemic thrombolysis or anticoagulation.</h4><i>Parks AL, Stevens SM</i><br /><AbstractText>Planer D, Yanko S, Matok I, et al. <b>Catheter-directed thrombolysis compared with systemic thrombolysis and anticoagulation in patients with intermediate- or high-risk pulmonary embolism: systematic review and network meta-analysis.</b> CMAJ. 2023;195:E833-E843. 37336568.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>In healthy older adults, low-dose aspirin increased incident anemia at a median 4.7 y.</h4><i>Carlin S, Eikelboom JW</i><br /><AbstractText>McQuilten ZK, Thao LT, Pasricha SR, et al. <b>Effect of low-dose aspirin versus placebo on incidence of anemia in the elderly: a secondary analysis of the Aspirin in Reducing Events in the Elderly trial.</b> Ann Intern Med. 2023;176:913-921. 37335992.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Atrial Fibrillation Recurrence in Patients With Transient New-Onset Atrial Fibrillation Detected During Hospitalization for Noncardiac Surgery or Medical Illness : A Matched Cohort Study.</h4><i>McIntyre WF, Vadakken ME, Connolly SJ, Mendoza PA, ... Whitlock RP, Healey JS</i><br /><b>Background</b><br />Atrial fibrillation (AF) is often detected for the first time in patients who are hospitalized for another reason. Long-term risks for AF recurrence in these patients are unclear.<br /><b>Objective</b><br />To estimate risk for AF recurrence in patients with new-onset AF during a hospitalization for noncardiac surgery or medical illness compared with a matched population without AF.<br /><b>Design</b><br />Matched cohort study. (ClinicalTrials.gov: NCT03221777).<br /><b>Setting</b><br />Three academic hospitals in Hamilton, Ontario, Canada.<br /><b>Participants</b><br />The study enrolled patients hospitalized for noncardiac surgery or medical illness who had transient new-onset AF. For each participant, an age- and sex-matched control participant with no history of AF from the same hospital ward was recruited. All participants left the hospital in sinus rhythm.<br /><b>Measurements</b><br />14-day electrocardiographic (ECG) monitor at 1 and 6 months and telephone assessment at 1, 6, and 12 months. The primary outcome was AF lasting at least 30 seconds on the monitor or captured by ECG 12-lead during routine care at 12 months.<br /><b>Results</b><br />Among 139 participants with transient new-onset AF (70 patients with medical illness and 69 surgical patients) and 139 matched control participants, the mean age was 71 years (SD, 10), the mean CHA<sub>2</sub>DS<sub>2</sub>-VASc score was 3.0 (SD, 1.5), and 59% were male. The median duration of AF during the index hospitalization was 15.8 hours (IQR, 6.4 to 49.6 hours). After 1 year, recurrent AF was detected in 33.1% (95% CI, 25.3% to 40.9%) of participants in the transient new-onset AF group and 5.0% (CI, 1.4% to 8.7%) of matched control participants; after adjustment for the number of ECG monitors worn and for baseline clinical differences, the adjusted relative risk was 6.6 (CI, 3.2 to 13.7). After exclusion of participants who had electrical or pharmacologic cardioversion during the index hospitalization (<i>n</i> = 40) and their matched control participants and limiting to AF events detected by the patch ECG monitor, recurrent AF was detected in 32.3% (CI, 23.1% to 41.5%) of participants with transient new-onset AF and 3.0% (CI, 0% to 6.4%) of matched control participants.<br /><b>Limitations</b><br />Generalizability is limited, and the study was underpowered to evaluate subgroups and clinical predictors.<br /><b>Conclusion</b><br />Among patients who have transient new-onset AF during a hospitalization for noncardiac surgery or medical illness, approximately 1 in 3 will have recurrent AF within 1 year.<br /><b>Primary funding source</b><br />Peer-reviewed grants.<br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Suspected Bronchiectasis and Mortality in Adults With a History of Smoking Who Have Normal and Impaired Lung Function : A Cohort Study.</h4><i>Diaz AA, Wang W, Orejas JL, Elalami R, ... Cho MH, San José Estépar R</i><br /><b>Background</b><br />Bronchiectasis in adults with chronic obstructive pulmonary disease (COPD) is associated with greater mortality. However, whether suspected bronchiectasis-defined as incidental bronchiectasis on computed tomography (CT) images plus clinical manifestation-is associated with increased mortality in adults with a history of smoking with normal spirometry and preserved ratio impaired spirometry (PRISm) is unknown.<br /><b>Objective</b><br />To determine the association between suspected bronchiectasis and mortality in adults with normal spirometry, PRISm, and obstructive spirometry.<br /><b>Design</b><br />Prospective, observational cohort.<br /><b>Setting</b><br />The COPDGene (Genetic Epidemiology of Chronic Obstructive Pulmonary Disease) study.<br /><b>Participants</b><br />7662 non-Hispanic Black or White adults, aged 45 to 80 years, with 10 or more pack-years of smoking history. Participants who were former and current smokers were stratified into normal spirometry (<i>n</i> = 3277), PRISm (<i>n</i> = 986), and obstructive spirometry (<i>n</i> = 3399).<br /><b>Measurements</b><br />Bronchiectasis identified by CT was ascertained using artificial intelligence-based measurements of an airway-to-artery ratio (AAR) greater than 1 (AAR >1), a measure of bronchial dilatation. The primary outcome of \"suspected bronchiectasis\" was defined as an AAR >1 of greater than 1% plus 2 of the following: cough, phlegm, dyspnea, and history of 2 or more exacerbations.<br /><b>Results</b><br />Among the 7662 participants (mean age, 60 years; 52% women), 1352 (17.6%) had suspected bronchiectasis. During a median follow-up of 11 years, 2095 (27.3%) died. Ten-year mortality risk was higher in participants with suspected bronchiectasis, compared with those without suspected bronchiectasis (normal spirometry: difference in mortality probability [Pr], 0.15 [95% CI, 0.09 to 0.21]; PRISm: Pr, 0.07 [CI, -0.003 to 0.15]; obstructive spirometry: Pr, 0.06 [CI, 0.03 to 0.09]). When only CT was used to identify bronchiectasis, the differences were attenuated in the normal spirometry (Pr, 0.04 [CI, -0.001 to 0.08]).<br /><b>Limitations</b><br />Only 2 racial groups were studied. Only 1 measurement was used to define bronchiectasis on CT. Symptoms of suspected bronchiectasis were nonspecific.<br /><b>Conclusion</b><br />Suspected bronchiectasis was associated with a heightened risk for mortality in adults with normal and obstructive spirometry.<br /><b>Primary funding source</b><br />National Heart, Lung, and Blood Institute.<br /><br /><br /><br /><small>Ann Intern Med: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Regulatory Review Duration and Differences in Submission Times of Drugs in the United States and Europe, 2011 to 2020.</h4><i>Vokinger KN, Serra-Burriel M, Glaus CEG, Rohr UP, ... Dalla Torre di Sanguinetto S, Kesselheim AS</i><br /><AbstractText>The speed of drug regulatory agencies in the United States and Europe is often a source of discussion. The objective of this research was to assess regulatory review duration of first and supplementary indications approved between 2011 and 2020 in the United States and Europe (European Union [EU] and Switzerland) and differences in submission times between the United States and Europe. Descriptive statistics were applied to review times between the jurisdictions and across the therapeutic areas. A regression analysis was done to estimate the association between approval agency and review times. The primary analysis cohort included 241 drugs approved in the United States, the EU, and Switzerland. Of these, 128 drugs had supplemental indications (331 in total) in the United States and 87 had supplemental indications (206 in total) in the EU. Overall median review duration from submission to approval subtracting the clock stop period was 39 weeks in the United States, 44 weeks in the EU, and 44 weeks in Switzerland. When review times within each drug were compared, the European Medicines Agency took a median of 3.7 weeks (IQR, -6.7 to 14.9 weeks) longer than the U.S. Food and Drug Administration and Swissmedic a median of 0.3 weeks (IQR, -10.6 to 15.3 weeks) longer. Median total review duration for supplemental indications was 26 weeks in the United States and 40 weeks in the EU. Applications were submitted a median of 1.3 and 17.9 weeks later in the EU and Switzerland, respectively, than in the United States. The regression analysis showed small differences in submission times between the United States and the EU (-2.1 weeks [95% CI, -11.7 to 7.6 weeks]) and larger differences between the United States and Switzerland (33.0 weeks [CI, 23.1 to 42.8 weeks]). It would be beneficial for patients if differences in submission times between the United States and Europe continue to be minimized.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 01 Oct 2023; 176:1413-1418</small></div>

<div><h4>Telemedicine Versus In-Person Primary Care: Treatment and Follow-up Visits.</h4><i>Reed M, Huang J, Somers M, Hsueh L, ... Muelly E, Gopalan A</i><br /><b>Background</b><br />Beyond initial COVID-19 pandemic emergency expansions of telemedicine use, it is unclear how well primary care telemedicine addresses patients\' needs.<br /><b>Objective</b><br />To compare treatment and follow-up visits (office, emergency department, hospitalization) between primary care video or telephone telemedicine and in-person office visits.<br /><b>Design</b><br />Retrospective design based on administrative and electronic health record (EHR) data.<br /><b>Setting</b><br />Large, integrated health care delivery system with more than 1300 primary care providers, between April 2021 and December 2021 (including the COVID-19 pandemic Delta wave).<br /><b>Patients</b><br />1 589 014 adult patients; 26.5% were aged 65 years or older, 54.9% were female, 22.2% were Asian, 7.4% were Black, 22.3% were Hispanic, 46.5% were White, 21.5% lived in neighborhoods with lower socioeconomic status, and 31.8% had a chronic health condition.<br /><b>Measurements</b><br />Treatment outcomes included medication or antibiotic prescribing and laboratory or imaging ordering. Follow-up visits included in-person visits to the primary care office or emergency department or hospitalization within 7 days. Outcomes were adjusted for sociodemographic and clinical characteristics overall and stratified by clinical area (abdominal pain, gastrointestinal concerns, back pain, dermatologic concerns, musculoskeletal pain, routine care, hypertension or diabetes, and mental health).<br /><b>Results</b><br />Of 2 357 598 primary care visits, 50.8% used telemedicine (19.5% video and 31.3% telephone). After adjustment, medications were prescribed in 46.8% of office visits, 38.4% of video visits, and 34.6% of telephone visits. After the visit, 1.3% of in-person visits, 6.2% of video visits, and 7.6% of telephone visits had a 7-day return in-person primary care visit; 1.6% of in-person visits, 1.8% of video visits, and 2.1% of telephone visits were followed by an emergency department visit. Differences in follow-up office visits were largest after index office versus telephone visits for acute pain conditions and smallest for mental health.<br /><b>Limitations</b><br />In the study setting, telemedicine is fully integrated with ongoing EHRs and with clinicians, and the study examines an insured population during the late COVID-19 pandemic period. Observational comparison lacks detailed severity or symptom measures. Follow-up was limited to 7 days. Clinical area categorization uses diagnosis code rather than symptom.<br /><b>Conclusion</b><br />In-person return visits were somewhat higher after telemedicine compared with in-person primary care visits but varied by specific clinical condition.<br /><b>Primary funding source</b><br />Agency for Healthcare Research and Quality.<br /><br /><br /><br /><small>Ann Intern Med: 01 Oct 2023; 176:1349-1357</small></div>

<div><h4>Blood Pressure Level in Late Adolescence and Risk for Cardiovascular Events : A Cohort Study.</h4><i>Rietz H, Pennlert J, Nordström P, Brunström M</i><br /><b>Background</b><br />Not enough is known about the association between blood pressure (BP) in adolescence and future cardiovascular events.<br /><b>Objective</b><br />To measure this association using the 2017 American College of Cardiology/American Heart Association guidelines for classifying BP elevation.<br /><b>Design</b><br />Cohort study.<br /><b>Setting</b><br />Sweden.<br /><b>Participants</b><br />Males in late adolescence who were conscripted into the military from 1969 to 1997.<br /><b>Measurements</b><br />Baseline BP was measured at conscription. The primary outcome was a composite of cardiovascular death or first hospitalization for myocardial infarction, heart failure, ischemic stroke, or intracerebral hemorrhage.<br /><b>Results</b><br />The study included 1 366 519 males with a mean age of 18.3 years. The baseline BP was classified as elevated (120 to 129/<80 mm Hg) for 28.8% of participants and hypertensive (≥130/80 mm Hg) for 53.7%. During a median follow-up of 35.9 years, 79 644 had a primary outcome. The adjusted hazard ratio was 1.10 for elevated BP (95% CI, 1.07 to 1.13), 1.15 for stage 1 isolated systolic hypertension (ISH) (CI, 1.11 to 1.18), 1.23 for stage 1 isolated diastolic hypertension (IDH) (CI, 1.18 to 1.28), 1.32 for stage 1 systolic-diastolic hypertension (SDH) (CI, 1.27 to 1.37), 1.31 for stage 2 ISH (CI, 1.28 to 1.35), 1.55 for stage 2 IDH (CI, 1.42 to 1.69), and 1.71 for stage 2 SDH (CI, 1.58 to 1.84). The cumulative risk for cardiovascular events also increased gradually across BP stages, ranging from 14.7% for normal BP to 24.3% for stage 2 SDH at age 68 years.<br /><b>Limitation</b><br />This was an observational study of Swedish men.<br /><b>Conclusion</b><br />Increasing BP levels in late adolescence are associated with gradually increasing risks for major cardiovascular events, beginning at a BP level of 120/80 mm Hg.<br /><b>Primary funding source</b><br />Västerbotten County Council, Swedish Society for Medical Research, and Heart Foundation of Northern Sweden.<br /><br /><br /><br /><small>Ann Intern Med: 26 Sep 2023; epub ahead of print</small></div>

<div><h4>Once-Weekly Insulin Icodec With Dosing Guide App Versus Once-Daily Basal Insulin Analogues in Insulin-Naive Type 2 Diabetes (ONWARDS 5) : A Randomized Trial.</h4><i>Bajaj HS, Aberle J, Davies M, Donatsky AM, ... Lingvay I, Bode B</i><br /><b>Background</b><br />Inadequate dose titration and poor adherence to basal insulin can lead to suboptimal glycemic control in persons with type 2 diabetes (T2D). Once-weekly insulin icodec (icodec) is a basal insulin analogue that is in development and is aimed at reducing treatment burden.<br /><b>Objective</b><br />To compare the effectiveness and safety of icodec titrated with a dosing guide app (icodec with app) versus once-daily basal insulin analogues (OD analogues) dosed per standard practice.<br /><b>Design</b><br />52-week, randomized, open-label, parallel-group, phase 3a trial with real-world elements. (ClinicalTrials.gov: NCT04760626).<br /><b>Setting</b><br />176 sites in 7 countries.<br /><b>Participants</b><br />1085 insulin-naive adults with T2D.<br /><b>Intervention</b><br />Icodec with app or OD analogue (insulin degludec, insulin glargine U100, or insulin glargine U300).<br /><b>Measurements</b><br />The primary outcome was change in glycated hemoglobin (HbA<sub>1c</sub>) level from baseline to week 52. Secondary outcomes included patient-reported outcomes (Treatment Related Impact Measure for Diabetes [TRIM-D] compliance domain score and change in Diabetes Treatment Satisfaction Questionnaire [DTSQ] total treatment satisfaction score).<br /><b>Results</b><br />The estimated mean change in HbA<sub>1c</sub> level from baseline to week 52 was greater with icodec with app than with OD analogues, with noninferiority (<i>P</i> < 0.001) and superiority (<i>P</i> = 0.009) confirmed in prespecified hierarchical testing (estimated treatment difference [ETD], -0.38 percentage points [95% CI, -0.66 to -0.09 percentage points]). At week 52, patient-reported outcomes were more favorable with icodec with app than with OD analogues (ETDs, 3.04 [CI, 1.28 to 4.81] for TRIM-D and 0.78 [CI, 0.10 to 1.47] for DTSQ). Rates of clinically significant or severe hypoglycemia were low and similar with both treatments.<br /><b>Limitation</b><br />Inability to differentiate the effects of icodec and the dosing guide app.<br /><b>Conclusion</b><br />Compared with OD analogues, icodec with app showed superior HbA<sub>1c</sub> reduction and improved treatment satisfaction and compliance with similarly low hypoglycemia rates.<br /><b>Primary funding source</b><br />Novo Nordisk A/S.<br /><br /><br /><br /><small>Ann Intern Med: 26 Sep 2023; epub ahead of print</small></div>

<div><h4>Ethical Guidance for Physicians and Health Care Institutions on Grateful Patient Fundraising: A Position Paper From the American College of Physicians.</h4><i>Snyder Sulmasy L, Callister TB, Opole IO, Deep NN, American College of Physicians Ethics, Professionalism and Human Rights Committee</i><br /><AbstractText>Physician solicitation of charitable contributions from patients-also known among other things as grateful patient fundraising-raises significant ethical concerns. These include pressure on patients to donate and the effects of this on the patient-physician relationship, potential expectations of donor patients for treatment that is not indicated or preferential care, justice and fairness issues, disclosure and use of confidential patient information for nontreatment purposes, and conflicts of interest. The patient-physician relationship and knowledge of the patient\'s medical history, clinical status, personal information, and financial circumstances are some of the reasons development and administrative officials might see physicians as strong potential fundraisers. But those are among the reasons grateful patient fundraising is ethically problematic. This American College of Physicians position paper explores these issues and offers guidance.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 26 Sep 2023; epub ahead of print</small></div>

<div><h4>Outpatient Treatment of Confirmed COVID-19: Living, Rapid Practice Points From the American College of Physicians (Version 2).</h4><i>Qaseem A, Yost J, Abraham GM, Andrews R, ... Humphrey LL, Population Health and Medical Science Committee of the American College of Physicians</i><br /><b>Description</b><br />Evidence for the use of outpatient treatments in adults with confirmed COVID-19 continues to evolve with new data. This is version 2 of the American College of Physicians (ACP) living, rapid practice points focusing on 22 outpatient treatments for COVID-19, specifically addressing the dominant SARS-CoV-2 Omicron variant.<br /><b>Methods</b><br />The Population Health and Medical Science Committee (formerly the Scientific Medical Policy Committee) developed this version of the living, rapid practice points on the basis of a living, rapid review done by the ACP Center for Evidence Reviews at Cochrane Austria at the University for Continuing Education Krems (Danube University Krems). This topic will be maintained as living and rapid by continually monitoring and assessing the impact of new evidence.<br /><b>Practice point 1</b><br /><i>Consider molnupiravir to treat symptomatic patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 days of the onset of symptoms and at a high risk for progressing to severe disease.</i><br /><b>Practice point 2</b><br /><i>Consider nirmatrelvir-ritonavir combination therapy to treat symptomatic patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 days of the onset of symptoms and at a high risk for progressing to severe disease.</i><br /><b>Practice point 3</b><br /><i>Do not use ivermectin to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting.</i><br /><b>Practice point 4</b><br /><i>Do not use sotrovimab to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting.</i><br /><br /><br /><br /><small>Ann Intern Med: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Outpatient Treatment of Confirmed COVID-19: A Living, Rapid Evidence Review for the American College of Physicians (Version 2).</h4><i>Sommer I, Ledinger D, Thaler K, Dobrescu A, ... Klerings I, Gartlehner G</i><br /><b>Background</b><br />Clinicians and patients want to know the benefits and harms of outpatient treatment options for the Omicron variant of SARS-CoV-2.<br /><b>Purpose</b><br />To assess the benefits and harms of 22 different COVID-19 treatments.<br /><b>Data sources</b><br />The Epistemonikos COVID-19 L·OVE platform, the iSearch COVID-19 portfolio, and the World Health Organization (WHO) COVID-19 Research Database from 26 November 2021 to 2 March 2023.<br /><b>Study selection</b><br />Two reviewers independently screened abstracts and full texts against a priori-defined criteria.<br /><b>Data extraction</b><br />One reviewer extracted the data and assessed the risk of bias and certainty of evidence (COE). A second reviewer verified the data abstraction and assessments.<br /><b>Data synthesis</b><br />Two randomized controlled trials and 6 retrospective cohort studies were included. Nirmatrelvir-ritonavir was associated with a reduction in hospitalization due to COVID-19 (for example, 0.7% vs. 1.2%; moderate COE) and all-cause mortality (for example, <0.1% vs. 0.2%; moderate COE). Molnupiravir led to a higher recovery rate (31.8% vs. 22.6%; moderate COE) and reduced time to recovery (9 vs. 15 median days; moderate COE) but had no effect on all-cause mortality (0.02% vs. 0.04%; moderate COE) and the incidence of serious adverse events (0.4% vs. 0.3%; moderate COE). Ivermectin had no effect on time to recovery (moderate COE) and resulted in no difference in adverse events compared with placebo (low COE). Sotrovimab resulted in no difference in all-cause mortality compared with no treatment (low COE). No eligible studies for all other treatments of interest were identified.<br /><b>Limitation</b><br />Evidence for nirmatrelvir-ritonavir and sotrovimab is based on nonrandomized studies only.<br /><b>Conclusion</b><br />Nirmatrelvir-ritonavir and molnupiravir probably improve outcomes for outpatients with mild to moderate COVID-19.<br /><b>Primary funding source</b><br />American College of Physicians. (PROSPERO: CRD42023406456).<br /><br /><br /><br /><small>Ann Intern Med: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Travel Medicine.</h4><i>Rolfe RJ, Ryan ET, LaRocque RC</i><br /><AbstractText>International travel can cause new illness or exacerbate existing conditions. Because primary care providers are frequent sources of health advice to travelers, they should be familiar with destination-specific disease risks, be knowledgeable about travel and routine vaccines, be prepared to prescribe chemoprophylaxis and self-treatment regimens, and be aware of travel medicine resources. Primary care providers should recognize travelers who would benefit from referral to a specialized travel clinic for evaluation. Those requiring yellow fever vaccination, immunocompromised hosts, pregnant persons, persons with multiple comorbid conditions, or travelers with complex itineraries may warrant specialty referral.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 12 Sep 2023; epub ahead of print</small></div>

<div><h4>Chronotype, Unhealthy Lifestyle, and Diabetes Risk in Middle-Aged U.S. Women : A Prospective Cohort Study.</h4><i>Kianersi S, Liu Y, Guasch-Ferré M, Redline S, ... Sun Q, Huang T</i><br /><b>Background</b><br />Evening chronotype may promote adherence to an unhealthy lifestyle and increase type 2 diabetes risk.<br /><b>Objective</b><br />To evaluate the role of modifiable lifestyle behaviors in the association between chronotype and diabetes risk.<br /><b>Design</b><br />Prospective cohort study.<br /><b>Setting</b><br />Nurses\' Health Study II.<br /><b>Participants</b><br />63 676 nurses aged 45 to 62 years with no history of cancer, cardiovascular disease, or diabetes in 2009 were prospectively followed until 2017.<br /><b>Measurements</b><br />Self-reported chronotype using a validated question from the Morningness-Eveningness Questionnaire. The lifestyle behaviors that were measured were diet quality, physical activity, alcohol intake, body mass index (BMI), smoking, and sleep duration. Incident diabetes cases were self-reported and confirmed using a supplementary questionnaire.<br /><b>Results</b><br />Participants reporting a \"definite evening\" chronotype were 54% (95% CI, 49% to 59%) more likely to have an unhealthy lifestyle than participants reporting a \"definite morning\" chronotype. A total of 1925 diabetes cases were documented over 469 120 person-years of follow-up. Compared with the \"definite morning\" chronotype, the adjusted hazard ratio (HR) for diabetes was 1.21 (CI, 1.09 to 1.35) for the \"intermediate\" chronotype and 1.72 (CI, 1.50 to 1.98) for the \"definite evening\" chronotype after adjustment for sociodemographic factors, shift work, and family history of diabetes. Further adjustment for BMI, physical activity, and diet quality attenuated the association comparing the \"definite evening\" and \"definite morning\" chronotypes to 1.31 (CI, 1.13 to 1.50), 1.54 (CI, 1.34 to 1.77), and 1.59 (CI, 1.38 to 1.83), respectively. Accounting for all measured lifestyle and sociodemographic factors resulted in a reduced but still positive association (HR comparing \"definite evening\" vs. \"definite morning\" chronotype, 1.19 [CI, 1.03 to 1.37]).<br /><b>Limitations</b><br />Chronotype assessment using a single question, self-reported data, and homogeneity of the study population.<br /><b>Conclusion</b><br />Middle-aged nurses with an evening chronotype were more likely to report unhealthy lifestyle behaviors and had increased diabetes risk compared with those with a morning chronotype. Accounting for BMI, physical activity, diet, and other modifiable lifestyle factors attenuated much but not all of the increased diabetes risk.<br /><b>Primary funding source</b><br />National Institutes of Health.<br /><br /><br /><br /><small>Ann Intern Med: 12 Sep 2023; epub ahead of print</small></div>

<div><h4>Standards and Ethics Issues in the Determination of Death: A Position Paper From the American College of Physicians.</h4><i>DeCamp M, Prager K, American College of Physicians Ethics, Professionalism and Human Rights Committee*</i><br /><AbstractText>The determination of a patient\'s death is of considerable medical and ethical significance. Death is a biological concept with social implications. Acting with honesty, transparency, respect, and integrity is critical to trust in the patient-physician relationship, and the profession, in life and in death. Over time, cases about the determination of death have raised questions that need to be addressed. This American College of Physicians position paper addresses current controversies and supports a clarification to the Uniform Determination of Death Act; maintaining the 2 current independent standards of determining death, cardiorespiratory and neurologic; retaining the whole brain death standard; aligning medical testing with the standards; keeping issues about the determination of death separate from organ transplantation; reaffirming the importance and role of the dead donor rule; and engaging in educational efforts for health professionals, patients, and the public on these issues. Physicians should advocate for policies and practices on the determination of death that are consistent with the profession\'s fundamental and timeless commitment to individual patients and the public.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>CTFPHC recommends risk assessment-first screening to prevent fragility fractures in women aged ≥65 y.</h4><i>Ito K</i><br /><AbstractText>Thériault G, Limburg H, Klarenbach S, et al; Canadian Task Force on Preventive Health Care. <b>Recommendations on screening for primary prevention of fragility fractures.</b> CMAJ. 2023;195:E639-E649. 37156553.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>SGLT2 inhibitors improved health status in Black and White patients with HF regardless of race.</h4><i>Pandey A, Van Spall HGC</i><br /><AbstractText>Gupta K, Spertus JA, Birmingham M, et al. <b>Racial differences in quality of life in patients with heart failure treated with sodium-glucose cotransporter 2 inhibitors: a patient-level meta-analysis of the CHIEF-HF, DEFINE-HF, and PRESERVED-HF trials.</b> Circulation. 2023;148:220-228. 37191040.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>In adults with cancer and VTE, DOACs were noninferior to LMWH for recurrent, nonfatal VTE at 6 mo.</h4><i>Bannow BTS</i><br /><AbstractText>Schrag D, Uno H, Rosovsky R, et al; CANVAS Investigators. <b>Direct oral anticoagulants vs low-molecular-weight heparin and recurrent VTE in patients with cancer: a randomized clinical trial.</b> JAMA. 2023;329:1924-1933. 37266947.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>The 3D-CAM 3-minute interview has 92% sensitivity and 95% specificity for detecting delirium in various care settings.</h4><i>Ramaswamy R</i><br /><AbstractText>Ma R, Zhao J, Li C, et al. <b>Diagnostic accuracy of the 3-minute diagnostic interview for confusion assessment method-defined delirium in delirium detection: a systematic review and meta-analysis.</b> Age Ageing. 2023;52:afad074. 37211364.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Evidence-Based Cardiovascular Disease Medicines\' Availability in Low-Cost Generic Drug Programs in the United States : A Cross-Sectional Study.</h4><i>Ton IT, Moon J, Sengul A, Mody FV, ... Han JK, Jackevicius CA</i><br /><b>Background</b><br />Low-cost generic programs (LCGPs) that expand access to affordable cardiovascular disease (CVD) medicines can assist patients in achieving desired cardiovascular outcomes. It is important that LCGPs offer CVD medicines that promote evidence-based prescribing.<br /><b>Objective</b><br />To evaluate LCGPs\' coverage of evidence-based CVD medications using a clinical framework that examines coverage of core treatments, coverage of options with the highest-quality evidence, and the variety of medication options and strengths that create choices and allow dosing titration.<br /><b>Design</b><br />Cross-sectional study.<br /><b>Setting</b><br />Publicly available LCGPs in March and April 2023 in the United States.<br /><b>Participants</b><br />19 LCGPs.<br /><b>Measurements</b><br />Proportion of LCGPs that offered evidence-based CVD medicines within a clinical framework for 6 CVDs (atrial fibrillation, heart failure, hyperlipidemia, hypertension, post-acute coronary syndrome secondary prevention, and stable angina) according to 4 availability metrics (breadth, choice, high-quality evidence, and titratability).<br /><b>Results</b><br />The availability of CVD medication varied by program, drug, and CVD condition. Some programs had more breadth and choice of coverage for most CVDs (H-E-B, Kroger, Mark Cuban Cost Plus Drug Company, and Walmart), whereas many had more focused coverage and others markedly limited offerings. Nearly all LCGPs offered angiotensin-converting enzyme inhibitors, β-blockers, thiazides, and moderate-intensity statins, but availability was low for higher-cost or lower-use generics (antiplatelets and antiarrhythmics). Core pharmacotherapy coverage and choices were limited for atrial fibrillation and heart failure but widely available for hypertension and hyperlipidemia.<br /><b>Limitation</b><br />In-depth cost analysis was not investigated.<br /><b>Conclusion</b><br />Coverage of evidence-based medications for the 6 CVDs investigated varied by LCGP and condition. Because high availability of core CVD pharmacotherapy can enhance optimal disease state management, LCGPs should identify existing limitations in their coverage and continuously revise their formularies to improve the comprehensiveness of CVD medication coverage.<br /><b>Primary funding source</b><br />None.<br /><br /><br /><br /><small>Ann Intern Med: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Comparative Safety Analysis of Oral Antipsychotics for In-Hospital Adverse Clinical Events in Older Adults After Major Surgery : A Nationwide Cohort Study.</h4><i>Kim DH, Lee SB, Park CM, Levin R, ... Marcantonio ER, Inouye SK</i><br /><b>Background</b><br />Antipsychotics are commonly used to manage postoperative delirium. Recent studies reported that haloperidol use has declined, and atypical antipsychotic use has increased over time.<br /><b>Objective</b><br />To compare the risk for in-hospital adverse events associated with oral haloperidol, olanzapine, quetiapine, and risperidone in older patients after major surgery.<br /><b>Design</b><br />Retrospective cohort study.<br /><b>Setting</b><br />U.S. hospitals in the Premier Healthcare Database.<br /><b>Patients</b><br />17 115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018.<br /><b>Interventions</b><br />Haloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg).<br /><b>Measurements</b><br />The risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) were estimated after propensity score overlap weighting.<br /><b>Results</b><br />The weighted population had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%. Among the 4 antipsychotics, quetiapine was the most prescribed (53.0% of total exposure). There was no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group), olanzapine (2.8%; RR, 0.74 [95% CI, 0.42 to 1.27]), quetiapine (2.6%; RR, 0.70 [CI, 0.47 to 1.04]), and risperidone (3.3%; RR, 0.90 [CI, 0.53 to 1.41]). The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group.<br /><b>Limitation</b><br />Residual confounding by delirium severity; lack of untreated group; restriction to oral low-to-moderate dose treatment.<br /><b>Conclusion</b><br />These results suggest that atypical antipsychotics and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium who receive an oral low-to-moderate dose antipsychotic drug.<br /><b>Primary funding source</b><br />National Institute on Aging.<br /><br /><br /><br /><small>Ann Intern Med: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Lessons From the COVID-19 Pandemic: Updating Our Approach to Masking in Health Care Facilities.</h4><i>Chow EJ, Lynch JB, Zerr DM, Riedo FX, ... Lewis J, Duchin JS</i><br /><AbstractText>The COVID-19 pandemic has upended societal norms and changed the way the health risks associated with respiratory viral infections are viewed. In this commentary, the authors advocate for mindfulness of continuing areas of uncertainty along with integration of the lessons learned into hospital-based practices to prevent harm to vulnerable patients rather than reverting to suboptimal prepandemic behaviors.</AbstractText><br /><br /><br /><br /><small>Ann Intern Med: 31 Aug 2023; 176:1266-1268</small></div>

<div><h4>Incidence of and Factors Associated With Recurrent Firearm Injury Among Patients Presenting to St. Louis Trauma Centers, 2010 to 2019 : A Cohort Study.</h4><i>Mueller KL, Cooper BP, Moran V, Lew D, ... Ranney ME, Foraker RE</i><br /><b>Background</b><br />Firearm injuries are a public health crisis in the United States.<br /><b>Objective</b><br />To examine the incidence and factors associated with recurrent firearm injuries and death among patients presenting with an acute (index), nonfatal firearm injury.<br /><b>Design</b><br />Multicenter, observational, cohort study.<br /><b>Setting</b><br />Four adult and pediatric level I trauma hospitals in St. Louis, Missouri, 2010 to 2019.<br /><b>Participants</b><br />Consecutive adult and pediatric patients (<i>n</i> = 9553) presenting to a participating hospital with a nonfatal acute firearm injury.<br /><b>Measurements</b><br />Data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and death were collected from the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository. The Centers for Disease Control and Prevention (CDC) Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients\' residences. Analysis included descriptive statistics and time-to-event analyses estimating the probability of experiencing a recurrent firearm injury.<br /><b>Results</b><br />We identified 10 293 acutely firearm-injured patients of whom 9553 survived the injury and comprised the analytic sample. Over a median follow-up of 3.5 years (IQR, 1.5 to 6.4 years), 1155 patients experienced a recurrent firearm injury including 5 firearm suicides and 149 fatal firearm injuries. Persons experiencing recurrent firearm injury were young (25.3 ± 9.5 years), predominantly male (93%), Black (96%), and uninsured (50%), and resided in high social vulnerability regions (65%). The estimated risk for firearm reinjury was 7% at 1 year and 17% at 8 years.<br /><b>Limitations</b><br />Limited data on comorbidities and patient-level social determinants of health. Inability to account for recurrent injuries presenting to nonstudy hospitals.<br /><b>Conclusion</b><br />Recurrent injury and death are frequent among survivors of firearm injury, particularly among patients from socially vulnerable areas. Our findings highlight the need for interventions to prevent recurrence.<br /><b>Primary funding source</b><br />Emergency Medicine Foundation-AFFIRM and Missouri Foundation for Health.<br /><br /><br /><br /><small>Ann Intern Med: 29 Aug 2023; epub ahead of print</small></div>

<div><h4>Real-Time Computer-Aided Detection of Colorectal Neoplasia During Colonoscopy : A Systematic Review and Meta-analysis.</h4><i>Hassan C, Spadaccini M, Mori Y, Foroutan F, ... Rex DK, Repici A</i><br /><b>Background</b><br />Artificial intelligence computer-aided detection (CADe) of colorectal neoplasia during colonoscopy may increase adenoma detection rates (ADRs) and reduce adenoma miss rates, but it may increase overdiagnosis and overtreatment of nonneoplastic polyps.<br /><b>Purpose</b><br />To quantify the benefits and harms of CADe in randomized trials.<br /><b>Design</b><br />Systematic review and meta-analysis. (PROSPERO: CRD42022293181).<br /><b>Data sources</b><br />Medline, Embase, and Scopus databases through February 2023.<br /><b>Study selection</b><br />Randomized trials comparing CADe-assisted with standard colonoscopy for polyp and cancer detection.<br /><b>Data extraction</b><br />Adenoma detection rate (proportion of patients with ≥1 adenoma), number of adenomas detected per colonoscopy, advanced adenoma (≥10 mm with high-grade dysplasia and villous histology), number of serrated lesions per colonoscopy, and adenoma miss rate were extracted as benefit outcomes. Number of polypectomies for nonneoplastic lesions and withdrawal time were extracted as harm outcomes. For each outcome, studies were pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.<br /><b>Data synthesis</b><br />Twenty-one randomized trials on 18 232 patients were included. The ADR was higher in the CADe group than in the standard colonoscopy group (44.0% vs. 35.9%; relative risk, 1.24 [95% CI, 1.16 to 1.33]; low-certainty evidence), corresponding to a 55% (risk ratio, 0.45 [CI, 0.35 to 0.58]) relative reduction in miss rate (moderate-certainty evidence). More nonneoplastic polyps were removed in the CADe than the standard group (0.52 vs. 0.34 per colonoscopy; mean difference [MD], 0.18 polypectomy [CI, 0.11 to 0.26 polypectomy]; low-certainty evidence). Mean inspection time increased only marginally with CADe (MD, 0.47 minute [CI, 0.23 to 0.72 minute]; moderate-certainty evidence).<br /><b>Limitations</b><br />This review focused on surrogates of patient-important outcomes. Most patients, however, may consider cancer incidence and cancer-related mortality important outcomes. The effect of CADe on such patient-important outcomes remains unclear.<br /><b>Conclusion</b><br />The use of CADe for polyp detection during colonoscopy results in increased detection of adenomas but not advanced adenomas and in higher rates of unnecessary removal of nonneoplastic polyps.<br /><b>Primary funding source</b><br />European Commission Horizon 2020 Marie Skłodowska-Curie Individual Fellowship.<br /><br /><br /><br /><small>Ann Intern Med: 29 Aug 2023; epub ahead of print</small></div>

<div><h4>Factors Associated With Circulating Sex Hormones in Men : Individual Participant Data Meta-analyses.</h4><i>Marriott RJ, Murray K, Adams RJ, Antonio L, ... Wu FCW, Yeap BB</i><br /><b>Background</b><br />Various factors modulate circulating testosterone in men, affecting interpretation of testosterone measurements.<br /><b>Purpose</b><br />To clarify factors associated with variations in sex hormone concentrations.<br /><b>Data sources</b><br />Systematic literature searches (to July 2019).<br /><b>Study selection</b><br />Prospective cohort studies of community-dwelling men with total testosterone measured using mass spectrometry.<br /><b>Data extraction</b><br />Individual participant data (IPD) (9 studies; <i>n</i> = 21 074) and aggregate data (2 studies; <i>n</i> = 4075). Sociodemographic, lifestyle, and health factors and concentrations of total testosterone, sex hormone-binding globulin (SHBG), luteinizing hormone (LH), dihydrotestosterone, and estradiol were extracted.<br /><b>Data synthesis</b><br />Two-stage random-effects IPD meta-analyses found a nonlinear association of testosterone with age, with negligible change among men aged 17 to 70 years (change per SD increase about the midpoint, -0.27 nmol/L [-7.8 ng/dL] [CI, -0.71 to 0.18 nmol/L {-20.5 to 5.2 ng/dL}]) and decreasing testosterone levels with age for men older than 70 years (-1.55 nmol/L [-44.7 ng/dL] [CI, -2.05 to -1.06 nmol/L {-59.1 to -30.6 ng/dL}]). Testosterone was inversely associated with body mass index (BMI) (change per SD increase, -2.42 nmol/L [-69.7 ng/dL] [CI, -2.70 to -2.13 nmol/L {-77.8 to -61.4 ng/dL}]). Testosterone concentrations were lower for men who were married (mean difference, -0.57 nmol/L [-16.4 ng/dL] [CI, -0.89 to -0.26 nmol/L {-25.6 to -7.5 ng/dL}]); undertook at most 75 minutes of vigorous physical activity per week (-0.51 nmol/L [-14.7 ng/dL] [CI, -0.90 to -0.13 nmol/L {-25.9 to -3.7 ng/dL}]); were former smokers (-0.34 nmol/L [-9.8 ng/dL] [CI, -0.55 to -0.12 nmol/L {-15.9 to -3.5 ng/dL}]); or had hypertension (-0.53 nmol/L [-15.3 ng/dL] [CI, -0.82 to -0.24 nmol/L {-23.6 to -6.9 ng/dL}]), cardiovascular disease (-0.35 nmol/L [-10.1 ng/dL] [CI, -0.55 to -0.15 nmol/L {-15.9 to -4.3 ng/dL}]), cancer (-1.39 nmol/L [-40.1 ng/dL] [CI, -1.79 to -0.99 nmol/L {-51.6 to -28.5 ng/dL}]), or diabetes (-1.43 nmol/L [-41.2 ng/dL] [CI, -1.65 to -1.22 nmol/L {-47.6 to -35.2 ng/dL}]). Sex hormone-binding globulin was directly associated with age and inversely associated with BMI. Luteinizing hormone was directly associated with age in men older than 70 years.<br /><b>Limitation</b><br />Cross-sectional analysis, heterogeneity between studies and in timing of blood sampling, and imputation for missing data.<br /><b>Conclusion</b><br />Multiple factors are associated with variation in male testosterone, SHBG, and LH concentrations. Reduced testosterone and increased LH concentrations may indicate impaired testicular function after age 70 years. Interpretation of individual testosterone measurements should account particularly for age older than 70 years, obesity, diabetes, and cancer.<br /><b>Primary funding source</b><br />Medical Research Future Fund, Government of Western Australia, and Lawley Pharmaceuticals. (PROSPERO: CRD42019139668).<br /><br /><br /><br /><small>Ann Intern Med: 29 Aug 2023; epub ahead of print</small></div>

<div><h4>Role of Artificial Intelligence in Colonoscopy Detection of Advanced Neoplasias : A Randomized Trial.</h4><i>Mangas-Sanjuan C, de-Castro L, Cubiella J, Díez-Redondo P, ... Jover R, CADILLAC study investigators*</i><br /><b>Background</b><br />The role of computer-aided detection in identifying advanced colorectal neoplasia is unknown.<br /><b>Objective</b><br />To evaluate the contribution of computer-aided detection to colonoscopic detection of advanced colorectal neoplasias as well as adenomas, serrated polyps, and nonpolypoid and right-sided lesions.<br /><b>Design</b><br />Multicenter, parallel, randomized controlled trial. (ClinicalTrials.gov: NCT04673136).<br /><b>Setting</b><br />Spanish colorectal cancer screening program.<br /><b>Participants</b><br />3213 persons with a positive fecal immunochemical test.<br /><b>Intervention</b><br />Enrollees were randomly assigned to colonoscopy with or without computer-aided detection.<br /><b>Measurements</b><br />Advanced colorectal neoplasia was defined as advanced adenoma and/or advanced serrated polyp.<br /><b>Results</b><br />The 2 comparison groups showed no significant difference in advanced colorectal neoplasia detection rate (34.8% with intervention vs. 34.6% for controls; adjusted risk ratio [aRR], 1.01 [95% CI, 0.92 to 1.10]) or the mean number of advanced colorectal neoplasias detected per colonoscopy (0.54 [SD, 0.95] with intervention vs. 0.52 [SD, 0.95] for controls; adjusted rate ratio, 1.04 [99.9% CI, 0.88 to 1.22]). Adenoma detection rate also did not differ (64.2% with intervention vs. 62.0% for controls; aRR, 1.06 [99.9% CI, 0.91 to 1.23]). Computer-aided detection increased the mean number of nonpolypoid lesions (0.56 [SD, 1.25] vs. 0.47 [SD, 1.18] for controls; adjusted rate ratio, 1.19 [99.9% CI, 1.01 to 1.41]), proximal adenomas (0.94 [SD, 1.62] vs. 0.81 [SD, 1.52] for controls; adjusted rate ratio, 1.17 [99.9% CI, 1.03 to 1.33]), and lesions of 5 mm or smaller (polyps in general and adenomas and serrated lesions in particular) detected per colonoscopy.<br /><b>Limitations</b><br />The high adenoma detection rate in the control group may limit the generalizability of the findings to endoscopists with low detection rates.<br /><b>Conclusion</b><br />Computer-aided detection did not improve colonoscopic identification of advanced colorectal neoplasias.<br /><b>Primary funding source</b><br />Medtronic.<br /><br /><br /><br /><small>Ann Intern Med: 29 Aug 2023; epub ahead of print</small></div>