Annals of Internal Medicine最新文献

Background: Social determinants of health (SDOH) can affect metabolic health.

Objective: To determine the effect of social vulnerability on the comparative effectiveness of metabolic bariatric surgery or medical and lifestyle intervention on glycemia and weight outcomes in people with type 2 diabetes (T2D).

Design: Analysis of the effect modification of baseline Area Deprivation Index (ADI; a metric of social vulnerability) on longitudinal outcomes between randomized treatment groups using linear mixed-effects models. (ClinicalTrials.gov: NCT02328599).

Setting: 4 U.S. academic centers.

Participants: 258 participants with T2D enrolled in 4 randomized controlled trials of surgical versus medical management and a longitudinal observational follow-up study.

Measurements: ADI linked to ZIP code data at randomization; weight loss and hemoglobin A_1c (HbA_1c) level at the end of the active intervention period (7 to 12 years).

Results: Baseline characteristics were well balanced between the surgical and medical therapy groups after adjustment for study site and stratification by high versus low ADI. Surgery was more effective than medical therapy in reducing HbA_1c level among persons with high ADI (net difference, -1.29% [95% CI, -1.95% to -0.63%]) and those with low ADI (net difference, -0.95% [CI, -1.29% to -0.62%]). Surgery was also more effective than medical therapy at producing weight loss across ADIs, with respective net differences of -10.6% (CI, -15.2% to -5.9%) for high ADI and -13.3% (CI, -15.7% to -10.9%) for low ADI. The interaction between ADI and intervention group was not significant for either HbA_1c (P = 0.37) or weight loss (P = 0.31).

Limitations: Small sample size; parent trials were not designed to address effect modification by ADI.

Conclusion: Surgery was superior to medical therapy for people with T2D regardless of social deprivation. This study did not detect statistically significant differences in the comparative advantage of surgery over medical therapy by ADI.

Primary funding source: National Institutes of Health.

Background: Slow correction of severe hyponatremia is recommended to prevent osmotic demyelination syndrome but is associated with higher mortality.

Objective: To examine the association between sodium correction rates and death or delayed neurologic events.

Design: Retrospective cohort study.

Setting: Twenty-one community hospitals of an integrated health system in northern California.

Patients: Adults hospitalized with a serum sodium level of 120 mEq/L or lower between 2008 and 2023.

Intervention: Maximum 24-hour rate of serum sodium correction (slow [<8 mEq/L], medium [8 to 12 mEq/L], or fast [>12 mEq/L; reference]).

Measurements: The primary outcome was a composite of 90-day death or delayed neurologic events (new demyelination, paralysis, epilepsy, or altered consciousness between 3 and 90 days from admission). Standardized risk differences (RDs) were generated using targeted maximum likelihood estimation. Heterogeneity of effect was assessed across grades of predicted risk.

Results: 13 988 patients were hospitalized with severe hyponatremia during the study period (median age, 74 years; 63% female). Comorbidities included congestive heart failure (24%), liver disease (18%), alcohol dependence (14%), and metastatic cancer (10%). The primary outcome occurred in 3000 patients (21%); 90-day death occurred in 2554 (18%), and 90-day delayed neurologic events occurred in 587 (4%). Compared with slow 24-hour sodium correction, both medium (RD, -5.6 percentage points [95% CI, -7.1 to -4.0 percentage points]) and fast (RD, -9.0 percentage points [CI, -11.1 to -6.9 percentage points]) correction rates were associated with lower adjusted risk for the primary outcome. Risk differences increased with higher predicted risk, whereas risk ratios remained similar.

Limitations: Residual confounding; outcome ascertainment using diagnostic codes.

Conclusion: Faster sodium correction is associated with lower risk for 90-day death or delayed neurologic events. Treatment guidelines should be reexamined.

Primary funding source: The Permanente Medical Group Rapid Analytics Unit Program.