Annals of Internal Medicine最新文献

Most U.S. health plans use managed care strategies, including health care use management and clinician networks. Most Medicare, Medicaid, and commercial insurance enrollees are covered by managed care plans. Managed care is ostensibly used to steer patients toward high-quality clinicians and facilities and contain costs; however, prior authorization, narrow clinician networks, and other managed care strategies often restrict access to necessary care, causing frustration among patients and physicians. In this position paper, the American College of Physicians offers policy recommendations to protect patients from onerous managed care processes, reduce administrative burdens associated with managed care, and ensure that patients can promptly access high-value, medically necessary care.

Clinical impact ratings: GIM/FP/GP: [Formula: see text] Endocrinology: [Formula: see text] Gastroenterology: [Formula: see text].

Clinical impact ratings: GIM/FP/GP: [Formula: see text] Cardiology: [Formula: see text] Infectious Disease: [Formula: see text].

Background: The comparative gastrointestinal safety across glucagon-like peptide-1 receptor agonists and tirzepatide is still unclear.

Objective: To compare the risk for severe gastrointestinal adverse events across dulaglutide, subcutaneous semaglutide, and tirzepatide in patients with type 2 diabetes (T2D) in routine clinical practice.

Design: New-user, active-comparator cohort study.

Setting: Population-based study.

Participants: Adults with T2D initiating dulaglutide, subcutaneous semaglutide, and tirzepatide between 1 January 2019 and 30 August 2024 in 3 cohorts corresponding to 3 pairwise comparisons.

Measurements: The primary outcome was a composite of acute pancreatitis, biliary disease, bowel obstruction, gastroparesis, and severe constipation. Secondary outcomes of interest were the individual components of the primary outcome. Patients were 1:1 propensity score matched within each comparison. We calculated hazard ratios (HRs) with 95% CIs.

Results: There were 65 238 matched pairs in the semaglutide versus dulaglutide cohort, 20 893 in the tirzepatide versus dulaglutide cohort, and 46 620 in the tirzepatide versus semaglutide cohort. The HR of gastrointestinal events was 0.96 (95% CI, 0.87 to 1.06) in the semaglutide versus dulaglutide cohort, 0.96 (CI, 0.77 to 1.20) in the tirzepatide versus dulaglutide cohort, and 1.07 (CI, 0.90 to 1.26) in the tirzepatide versus semaglutide cohort.

Limitation: Possible residual confounding by glycemic control and body mass index.

Conclusion: These findings suggest that dulaglutide, semaglutide, and tirzepatide have similar gastrointestinal safety profiles in adults with T2D. This study provides clinicians with evidence to weigh the benefits and risks of these medications.

Primary funding source: National Institute of Diabetes and Digestive and Kidney Diseases.

Background: Seasonal influenza is a contagious viral respiratory illness that causes yearly epidemics.

Purpose: To assess the comparative effectiveness and harm of standard and newer and enhanced influenza vaccines in nonpregnant, nonimmunocompromised adults.

Data sources: Medline and Embase between May 2023 and July 2025, and a systematic review by the European Centre for Disease Prevention and Control (ECDC) to identify studies published before May 2023.

Study selection: Two investigators independently selected English-language randomized controlled trials (RCTs) and nonrandomized studies of interventions (NRSIs).

Data extraction: For newly included studies, one reviewer extracted data and assessed certainty of evidence (CoE), which was verified by a second reviewer; 2 reviewers independently assessed risk of bias. For studies from the ECDC report, original data and risk-of-bias assessments were used.

Data synthesis: The review included 35 RCTs and 5 NRSIs. Compared with standard vaccines, high-dose vaccines reduced laboratory-confirmed influenza in adults aged 65 years or older (high CoE) but increased the risk for fever in this group (high CoE). High-dose vaccines probably caused fewer serious adverse events in all adults and those aged 65 years or older (moderate CoE). Recombinant vaccines reduced laboratory-confirmed influenza in all adults and those younger than 65 years compared with standard vaccines (high CoE). Evidence from 2 RCTs indicated that mRNA vaccines may increase serious adverse events in all adults and those younger than 65 years compared with standard vaccines (low CoE).

Limitations: RCTs evaluating laboratory-confirmed influenza and influenza-related hospitalization or death are limited. Evidence was lacking for several comparisons and outcomes. Broad definitions of serious adverse events may have inflated risk estimates.

Conclusion: High-dose and recombinant vaccines improve protection compared with standard vaccines, but high-dose vaccines increase fever risk. Evidence for mRNA vaccines is limited and should be cautiously interpreted.

Primary funding source: American College of Physicians. (PROSPERO: CRD420251114496).

Background: A potential long-term complication of living kidney donation in male donors is scrotal swelling on the same side as the nephrectomy, and some undergo surgery to relieve discomfort from the fluid collection. The long-term risk for this outcome attributable to donation is unknown.

Objective: To evaluate long-term scrotal surgery rates after laparoscopic nephrectomy in male living kidney donors compared with nondonors.

Design: Population-based cohort study (2002 to 2024). (ClinicalTrials.gov: NCT06716723).

Setting: Linked administrative health care databases in Ontario, Canada.

Participants: 898 male living kidney donors who had a laparoscopic nephrectomy were matched in a 1:10 ratio with 8980 male nondonors from the general population. The matching characteristics were age, date of cohort entry, rural residence, income, prior vasectomy, and prior inguinal hernia repair. Participants were followed for a median of 9 years, up to 22 years.

Measurements: The primary outcome was hospitalization for surgery to address a unilateral scrotal fluid collection.

Results: Donors and matched nondonors had a median age of 45 years. The rate of scrotal surgery was higher in donors than nondonors (70 of 898 donors [7.8%] vs. 19 of 8980 nondonors [0.2%]; 8.3 vs. 0.2 events per 1000 person-years; hazard ratio, 38.8 [95% CI, 22.1 to 67.9]; P < 0.001). The median time from donation to scrotal surgery was 5.2 years (IQR, 3.3 to 8.4 years); more than 90% of the surgeries were hydrocelectomies and were performed under general anesthesia. Over 20 years, the cumulative incidence was 13.8% in donors versus 0.7% in nondonors.

Limitation: The precise causal mechanism remains unknown.

Conclusion: Laparoscopic nephrectomy is associated with a higher risk for subsequent scrotal surgery in male living kidney donors.

Primary funding source: Canadian Institutes of Health Research.