Annals of Internal Medicine最新文献

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: 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 OperA (Optimising Colorectal Cancer Prevention through Personalized Treatment with Artificial Intelligence) project aims to transform colorectal cancer care through artificial intelligence (AI) innovations. Recognizing that legal and ethical challenges remain key obstacles to clinical integration, this Delphi study sought to identify and prioritize such concerns in the context of gastrointestinal (GI) endoscopy. Fourteen international experts participated in a 2-round Delphi process. In round 1, the steering committee, with feedback from participants, proposed legal and ethical issues pertaining to AI in endoscopy. Round 2 involved iterative rating and refinement of these issues to achieve consensus on their importance. Consensus was reached on 10 key statements spanning 3 thematic domains: data governance, medicolegal implications, and equity and bias. Experts emphasized the need for robust data protection, transparent algorithmic development, and institutional clarity on data ownership. Liability concerns related to AI-assisted diagnosis and automated reporting were highlighted, alongside calls for guidance from legal and professional bodies. Finally, participants underscored the importance of demographic diversity in training data sets and transparent reporting practices to mitigate bias and ensure equitable AI deployment. As AI tools become increasingly integrated into the clinical practice of gastroenterology, addressing legal, ethical, and equity-related challenges is essential. This expert consensus provides a foundation for developing guidelines and regulatory frameworks to support responsible AI adoption in GI endoscopy.

The digitization of academic publications and newspapers from the 1800s has permitted identification of several authoritative sources that credit Dr. Joseph W. Gleitsmann with establishing the first successful tuberculosis sanitarium in the United States in Asheville, North Carolina, in 1875, antedating by 9 years the Trudeau Sanatorium in Saranac Lake, New York. The facility used German climatological methods and a defined medical treatment program. Gleitsmann's Mountain Sanitarium for Pulmonary Diseases had a 30-bed occupancy and published outcomes data from 5 years of clinical experience by 1880. By 1910, Asheville had become a tuberculosis care "colony," with 25 private tuberculosis sanitaria with a national referral base. Asheville was a key driver of the development of climatotherapy in the treatment of tuberculosis and other respiratory ailments in the preantibiotic era. From 1870 to 1930, medical, mental health, and wellness tourism largely drove the population growth (1500 to 50 000) of Asheville, a previously remote Appalachian town. The stigmatization of tuberculosis sufferers is illustrated by restrictive municipal regulations that led to the demolition of almost all tuberculosis sanitaria within Asheville city limits by the 1920s. The Von Ruck Research Laboratory for Tuberculosis produced more than 50 papers from 1890 to 1930, published mostly in the Journal of the American Medical Association and the Journal of Immunology. These included pioneering immunotherapy studies with tuberculin variants and the first robust description of the antigenic profile of Mycobacterium tuberculosis. Tuberculosis was both incurable and a leading cause of death, and thus perseverance with fractionated tubercle bacillus products and subunits by so many is understandable in the context of the times. By analogy, public health now seems more ready to accept disease-specific immunotherapy agents and vaccines that save lives even if they are substantially less than 100% effective.

Background: The benefit-risk profile of systemic corticosteroids in non-COVID-19 pneumonia and acute respiratory distress syndrome (ARDS) remains debated.

Purpose: To assess corticosteroid effects on mortality and infection-related complications in adults with severe pneumonia or ARDS.

Data sources: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform through September 2025.

Study selection: Randomized controlled trials comparing systemic corticosteroids with placebo and usual care. Primary analysis: severe pneumonia or ARDS with corticosteroids 3 mg/kg^-1 of body weight per day^-1 or less (prednisone-equivalent) for 15 days or less, initiated within 7 days.

Data extraction: Paired reviewers; consensus for disagreements.

Data synthesis: From 16 831 screened records, 20 studies (15 severe pneumonia, 5 ARDS) including 3459 participants met criteria. Low-dose, short-course corticosteroids probably reduce short-term mortality in severe pneumonia (15 studies, 2445 participants; risk ratio [RR], 0.73 [95% CI, 0.57 to 0.93]; I ²= 14%; moderate certainty) and ARDS (5 studies, 1014 participants; RR, 0.77 [CI, 0.61 to 0.99]; I ²= 23%; moderate certainty). Corticosteroids may reduce secondary shock in severe pneumonia (9 studies, 1690 participants; RR, 0.49 [CI, 0.26 to 0.92]; I ²= 55%; low certainty). They probably result in little to no difference in hospital-acquired infections (severe pneumonia: 7 studies, 1665 participants; RR, 0.99 [CI, 0.82 to 1.20]; I ²= 0%; moderate certainty; ARDS: 4 studies, 677 participants; RR, 0.97 [CI, 0.59 to 1.59]; I ²= 0%; low certainty) or secondary pneumonia (severe pneumonia: 4 studies, 1011 participants; RR, 0.96 [CI, 0.66 to 1.39]; I ²= 0%; ARDS: 4 studies, 677 participants; RR, 0.88 [CI, 0.43 to 1.79]; I ²= 0%; both low certainty). Evidence is very uncertain for catheter-related and bloodstream infections. Long-term mortality evidence is very uncertain for severe pneumonia.

Limitation: Heterogeneous pneumonia severity classification limiting subgroup precision.

Conclusion: In severe pneumonia and ARDS, adjunct corticosteroids probably reduce short-term mortality. In severe pneumonia, they may reduce secondary shock. In both conditions, corticosteroids may have little or no effect on hospital-acquired infections.

Primary funding source: None. (PROSPERO: CRD42024536301).