Annals of Internal Medicine最新文献

Background: Functional capacity is critical to preoperative risk assessment, yet guidance on its measurement in clinical practice remains lacking.

Purpose: To identify functional capacity assessment tools studied before surgery and characterize the extent of evidence regarding performance, including in populations where assessment is confounded by noncardiopulmonary reasons.

Data sources: MEDLINE, EMBASE, and EBM Reviews (until July 2024).

Study selection: Studies evaluating performance of functional capacity assessment tools administered before elective noncardiac surgery to stratify risk for postoperative outcomes.

Data extraction: Study details, measurement properties, pragmatic qualities, and/or clinical utility metrics.

Data synthesis: 6 categories of performance-based tests and 5 approaches using patient-reported exercise tolerance were identified. Cardiopulmonary exercise testing (CPET) was the most studied tool (132 studies, 32 662 patients) followed by field walking tests (58 studies, 9393 patients) among performance-based tests. Among patient-reported assessments, the Duke Activity Status Index (14 studies, 3303 patients) and unstructured assessments (19 studies, 28 520 patients) were most researched. Most evidence focused on predictive validity (92% of studies), specifically accuracy in predicting cardiorespiratory complications. Several tools lacked evidence on reliability (test consistency across similar measurements), pragmatic qualities (feasibility of implementation), or concurrent criterion validity (correlation to gold standard). Only CPET had evidence on clinical utility (whether administration improved postoperative outcomes). Older adults (≥65 years) were well represented across studies, whereas there were minimal data in patients with obesity, lower-limb arthritis, and disability.

Limitation: Synthesis focused on reported data without requesting missing information.

Conclusion: Though several tools for preoperative functional capacity assessment have been studied, research has overwhelmingly focused on CPET and only 1 aspect of validity (predictive validity). Important evidence gaps remain among vulnerable populations with obesity, arthritis, and physical disability.

Primary funding source: None. (Open Science Framework: https://osf.io/ah7u5).

Background: Polycystic ovary syndrome (PCOS) is common in women of reproductive age and is associated with obesity. Clinical guidelines recommend weight loss, but the impact on the clinical manifestations of PCOS is unclear.

Purpose: To quantify the effect of weight loss interventions on clinical features of PCOS, compared with usual care.

Data sources: MEDLINE, Embase, PsycINFO, CINAHL, Cochrane, Web of Science, and trial registries were searched from inception through June 2024.

Study selection: Randomized controlled trials comparing interventions aiming to reduce weight against usual care, including lower-intensity weight loss interventions in people with PCOS. Conversations with people with PCOS informed the outcomes.

Data extraction: Pairs of independent reviewers screened studies, extracted data, and assessed risk of bias (RoB). Outcomes included glycemic control (Homeostasis Model Assessment for Insulin Resistance [HOMA-IR], fasting insulin and glucose), hormonal markers (free androgen index [FAI] and other sex hormones), menstrual frequency, hirsutism, and PCOS-related quality of life (QoL). Pooled mean differences were obtained from random-effects meta-analysis with Knapp-Hartung adjustment.

Data synthesis: Primary analyses included 29 comparisons with 1529 participants: 13, 12, and 4 comparisons were judged as high, some, or low RoB, respectively. Twelve used behavioral interventions, 9 used glucagon-like peptide-1 (GLP1) agonists, and 8 used other weight loss medications. Weight loss interventions were associated with significantly greater improvements in HOMA-IR (mean difference, -0.45 [-0.75 to -0.15]; I ² = 24%), FAI (mean difference, -2.03 [-3.0 to -1.07]; I ² = 48%), and menstrual frequency (mean difference, 2.64 [0.65 to 4.63]; I²  = 43%). There was no evidence that weight loss interventions were associated with clinically or statistically significant improvements in hirsutism, QoL, or other sex hormones, which may be due to the limited power of the available data.

Limitation: There was high statistical heterogeneity in the interventions, comparators, and outcomes, largely unexplained by sensitivity and subgroup analyses.

Conclusion: Weight loss interventions were associated with improvements in some important features of PCOS and should be considered as a routine treatment option for people with PCOS.

Primary funding source: National Institute for Health and Care Research School for Primary Care Research. (PROSPERO: CRD42022367488).

Background: Late career physicians (LCPs; physicians working beyond age 65 to 75 years) may be at higher risk for delivering unsafe care. To oversee LCPs, some health care organizations (HCOs) have adopted LCP policies requiring cognitive, physical, and practice performance screening assessments. Despite recent controversies, little is known about the content and implementation of such policies.

Objective: To characterize key features of LCP policies and the perspectives of medical leaders responsible for policy development and implementation.

Design: Mixed-methods study using content analysis and key informant interviews.

Setting: 29 U.S. HCOs with LCP policies active in 2020.

Participants: 21 purposively sampled interviewees in physician leadership roles at 18 HCOs.

Measurements: Descriptive statistics of policy features and content analysis of interviews.

Results: Although policies had many commonalities-mandatory universal screening at a trigger age around 70 years, a strategy of screening followed by in-depth assessment of positive results, and commitment to patient safety as the key motive-they varied substantially in the testing required, funding, processes after a positive screening result, and decision making around concerning results. Policies prioritized institutional discretion in interpreting and responding to test results; many lacked clear language about appeals or other procedural protections for physicians. Leaders were generally satisfied with policies but reported preemptive retirements as physicians approached the screening age and cautioned that substantial investment in cultivating physicians' buy-in was required for successful rollout.

Limitations: Sampled policies and interviews may not be representative of all HCOs. The analysis excluded the experiences of HCOs that tried and failed to implement LCP screening.

Conclusion: Policies about LCPs are considered successful by institutional leaders. Policy variations and early adopters' implementation experiences highlight opportunities to improve physician acceptance and program rigor.

Primary funding source: The Greenwall Foundation.