Annals of Internal Medicine最新文献

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

Background: Diagnostic evaluation of positive screening results for lung cancer is critically important for optimal outcomes. Data on such follow-up are limited.

Objective: To assess the use of diagnostic tests after positive results on lung cancer screening in clinical practice.

Design: Retrospective cohort study.

Setting: U.S. institutions performing diagnostic follow-up of lung cancer screening, 2015 to 2022.

Participants: Persons with a first positive screening result at age 65 years or older who had Medicare fee-for-service coverage.

Measurements: Rates of diagnostic test use (imaging or invasive procedures) within 1 year of an index positive screening result and rates of receiving guideline-concordant follow-up care and of receiving less or more intensive (than guideline-concordant) care. Multiple logistic regression was used to assess factors associated with less or more intensive care.

Results: The cohort consisted of 64 555 persons. The rate of guideline-concordant care was 59.7% overall and increased with increasing Lung-RADS score: 49.2% for a score of 3, 68.6% for 4A, 74.1% for 4B, and 79.5% for 4X. Care was less intensive than recommended in 32.3% of participants, generally decreasing with Lung-RADS score: 39.3% for a score of 3, 24.7% for 4A, 25.9% for 4B, and 20.5% for 4X. Rates of more intensive care, applicable only for scores of 3 and 4A, were 11.5% and 6.7%, respectively. Among participants with Lung-RADS scores of 3 and 4A, non-Hispanic Black persons, those who currently smoked, and those undergoing baseline screening had significantly higher rates of less intensive care. Of all participants, 12.4% had a lung cancer diagnosis within 1 year. Invasive procedures were done in 16.2% of all participants and in 7.3% of those without eventual lung cancer.

Limitations: The cohort was limited to those in fee-for-service Medicare plans. Information on institutional and patient socioeconomic factors was limited.

Conclusion: About 60% of participants had guideline-concordant care, and about one third had less intensive care. Invasive procedure rates in those without cancer were low.

Primary funding source: None.

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

Frailty is a syndrome of decreased reserve across multiple physiologic systems that is associated with greater risk for hospitalizations, disability, institutionalization, and other adverse outcomes, including mortality. Patients with frailty, most of whom are older adults, may be more likely to experience adverse outcomes due to iatrogenic causes, such as higher-risk medications or procedures. Guidelines recommend frailty screening for both chronic disease management and in-hospital care, as identification of frailty allows for risk mitigation and alignment of care with patients' goals. In addition, some interventions may delay or reverse frailty, thus increasing physiologic reserve and improving day-to-day function. This article reviews frailty definitions, approaches to assessment in different care settings, and management.

Background: Mpox virus (MPXV) clade Ib, first detected in the Democratic Republic of the Congo (DRC) in September 2023, spread internationally within months, prompting an emergency declaration from the World Health Organization. Data on its incubation period, which both shapes outbreak dynamics and informs epidemic response strategies, remain limited.

Objective: To estimate the incubation periods of mpox clade Ib, examining evidence for differences by route of exposure and demographic factors.

Design: Bayesian analysis of clinical surveillance data collected between June and October 2024.

Setting: South Kivu, DRC, the epicenter of the current mpox clade Ib global outbreak.

Participants: Clinically attended persons with confirmed mpox clade Ib infection.

Measurements: Demographic characteristics, exposure history, symptom onset, and transmission route.

Results: Among 37 polymerase chain reaction-confirmed cases with high viral load (cycle threshold values <34), the median incubation period from exposure to rash was 13.6 days (95% credible interval [CrI], 9.6 to 19.0 days). Five percent of cases are expected to develop a rash within 3.1 days (CrI, 1.3 to 5.5 days) and 95% within 32.3 days (CrI, 22.4 to 45.8 days). The incubation period seemed to differ by putative transmission route: Sexual transmission had a shorter median (10.3 days [CrI, 3.1 to 20.3 days]) than nonsexual transmission (13.5 days [CrI, 9.5 to 19.1 days]), although the CrIs overlapped.

Limitation: Surveillance data lacked detailed exposure histories and a lower bound for exposure periods, but models accounted for these uncertainties, yielding robust median estimates.

Conclusion: Evidence from this study suggests that clade Ib may have a longer incubation period than other MPXV clades, and this may vary by transmission route. The shorter incubation for sexual transmission mirrors patterns seen in the predominantly sexually transmitted clade IIb outbreak, highlighting the potential role of exposure route in disease progression. These findings have implications for global recommendations on postexposure monitoring periods and prophylaxis.

Primary funding source: Gates Foundation and Geneva Centre for Emerging Viral Diseases.

The last 5 years in the United States have witnessed a flurry of policies attempting to limit access to gender-affirming care (GAC), with state and federal authorities instituting restrictions on care for transgender and gender-diverse (TGD) adolescents and attempting to limit funding for treatment costs. Although many have decried these policies as an unprecedented assault on GAC, there is actually a long history of attempts to limit access to GAC in the United States through the creation of restrictive policies directed at patients, clinicians, and payers. Even amid such restrictions, TGD people have demonstrated a remarkable ability to access GAC, often finding new ways to obtain this care. These have included shifts in tactics deployed by advocates of GAC as hostile policymakers attempted to limit the expansion of access. The current landscape of restrictive policies represents the culmination of a longstanding regulatory evolution, integrating various legislative approaches that have been used over almost a century. This article discusses how TGD communities have navigated several iterations of hostile legislative environments to access such care.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are used for type 2 diabetes mellitus (T2DM) and overweight or obesity, but their association with cancer is unclear.

Purpose: To investigate the risk for obesity-related cancer associated with GLP-1RAs.

Data sources: PubMed, Embase, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials from inception to August 2025.

Study selection: Randomized placebo-controlled trials reporting any of the following cancer outcomes: thyroid, pancreatic, colorectal, gastric, esophageal, liver, gallbladder, breast, ovarian, endometrial, or kidney cancer; multiple myeloma; or meningioma.

Data extraction: Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool, and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Odds ratios (ORs) were pooled using random-effects meta-analysis.

Data synthesis: The review included 48 trials involving 94 245 participants. GLP-1RAs probably have little or no effect on risk for thyroid cancer (OR, 1.37 [95% CI, 0.82 to 2.31]; 1 fewer to 9 more cases per 10 000 patients treated), pancreatic cancer (OR, 0.84 [CI, 0.53 to 1.35]; 9 fewer to 6 more per 10 000), breast cancer (OR, 0.95 [CI, 0.60 to 1.49]; 10 fewer to 12 more per 10 000), or kidney cancer (OR, 1.12 [CI, 0.78 to 1.60]; 5 fewer to 13 more per 10 000) (moderate certainty). GLP-1RAs may have little or no effect on colorectal, esophageal, liver, gallbladder, ovarian, or endometrial cancer; multiple myeloma; or meningioma (low certainty). The effect on gastric cancer is very uncertain. Results were consistent in sensitivity analyses of trials with low risk of bias and studies of semaglutide or tirzepatide and across subgroups stratified by follow-up duration, population, GLP-1RA class, weight loss profile, dose, and duration of action.

Limitation: The included trials were not designed to evaluate cancer outcomes and had short follow-up.

Conclusion: GLP-1RAs may have little or no effect on risk for obesity-related cancers. Longer-term studies are needed to clarify potential risks or benefits.

Primary funding source: None. (PROSPERO: CRD42024608365).