Annals of Internal Medicine最新文献

Reference tools are often uncritically accepted as balanced, objective, definitive, and evidence-based guides to medical knowledge. Yet for centuries textbooks and manuals have been entangled in various ways with industry interests. This essay shows how reference tools have served as sites of pharmaceutical promotion. Focusing on 2 reference tools, The Merck Manual and The Management of Pain, the authors sketch the complex and dynamic ways that Merck & Company and Purdue Frederick Company used medical reference texts to advance their market interests over the 20th century. Merck leveraged its eponymous Manual initially to promote its own products and later to elevate its brand name amid a public relations storm. Purdue's influence on pain medicine textbooks and prescribing manuals was less direct: By subsidizing the creation of pain medicine's flagship textbook and cultivating goodwill from key leaders, the company shaped the direction of many of the field's reference tools. As reference tools evolve over the 21st century, combining in new ways with machine-learning models, a historical perspective alerts us to the enduring influence, and vulnerabilities, of these aids to thought.

In recognition of accelerating health care spending and alignment with the American College of Physicians (ACP) principles of promoting high-value care, the ACP Clinical Guidelines Committee (CGC) developed a framework to standardize its approach to identifying, appraising, and considering economic evidence in the development of ACP clinical guidelines. This article presents the CGC's process for incorporating economic evidence, which encompasses cost-effectiveness analyses, economic outcomes in randomized controlled trials, and resource utilization (intervention cost) data. Economic evidence is one component of ACP recommendations. The CGC first and foremost assesses the certainty of evidence for clinical net benefit of interventions; it then considers patient values and preferences, and only then considers economic evidence to develop recommendations.

Background: Prior studies indicate that 1% to 4% of Epstein-Barr virus (EBV)-seronegative recipients of EBV-seropositive donor (EBV D+/R-) kidneys develop posttransplant lymphoproliferative disorder (PTLD). However, these estimates are based on limited data that lack granularity.

Objective: To determine the associations between pretransplant EBV D+/R- and recipient EBV-seropositive status (R+) and the outcomes of PTLD and graft and patient survival among adult kidney transplant recipients.

Design: Retrospective cohort study.

Setting: Two large U.S. transplant centers.

Participants: Epstein-Barr virus D+/R- and EBV R+ recipients matched 1:3 on donor, recipient, and transplant characteristics between 1 January 2010 and 30 June 2022.

Measurements: Exposure was pretransplant donor and recipient EBV serostatus. The primary outcome was biopsy-proven PTLD. Secondary outcomes were all-cause graft loss (death, retransplant, or graft failure) and death. Follow-up was truncated to 3 years after transplant.

Results: The final cohort comprised 104 EBV D+/R- recipients matched to 312 EBV R+ recipients. The mean age was 42 years (SD, 17.1), 59% were living donor transplants, and 95% received thymoglobulin induction. Among EBV D+/R- recipients, 50 (48.1%) developed EBV DNAemia, with a median time of 198 days (IQR, 110 to 282 days) after transplantation. Posttransplant lymphoproliferative disorder occurred in 23 (22.1%) EBV D+/R- recipients at a median of 202 days (IQR, 118 to 317 days) after transplantation. Epstein-Barr virus D+/R- recipients had higher all-cause graft failure (hazard ratio, 2.21 [95% CI, 1.06 to 4.63]); mortality was higher but not statistically significant (hazard ratio, 2.19 [CI, 0.94 to 5.13]).

Limitation: Two-center study.

Conclusion: Compared with previous studies, this study showed that EBV D+/R- kidney recipients face a 5- to 10-fold higher cumulative incidence of PTLD. Strategies to mitigate the PTLD risk are urgently needed.

Primary funding source: National Institutes of Health.

Clinical impact ratings: GIM/FP/GP: [Formula: see text] Critical Care: [Formula: see text].

Clinical impact ratings: GIM/FP/GP: [Formula: see text] Neurology: [Formula: see text] Hematology: [Formula: see text].

Atrial fibrillation (AF) is the most common arrhythmia. Risk factors for AF include obstructive sleep apnea, physical inactivity, obesity, cigarette use, and alcohol misuse. Atrial fibrillation substantially increases the risk for stroke and is associated with higher rates of mortality than for individuals without AF. Strategies to prevent these risk factors and to optimize those that already exist reduce the risk for subsequent AF. Physicians play an important role in proposing strategies to reduce the risk for AF among patients. Decision making regarding management of AF is often complex and requires consideration of symptoms, burden of AF (the percentage of time in AF), comorbid conditions that increase stroke risk, and the risk for bleeding. In particular, novel risk scoring systems to predict stroke risk, and consideration of factors beyond those in these tools, refine the ability to identify patients with AF who are most likely to benefit from anticoagulation to reduce stroke risk. Early use of catheter ablation of AF in selected patients improves symptoms and reduces the potential for progression from intermittent to persistent AF. A 2023 collaborative guideline from the American College of Cardiology, American Heart Association, American College of Chest Physicians, and the Heart Rhythm Society addressed multiple aspects of care of patients with AF. Here, a general cardiologist and a cardiac electrophysiologist discuss recommendations derived from this guideline and how to apply them to the care of a particular patient.