The comparative gastrointestinal safety across glucagon-like peptide-1 receptor agonists and tirzepatide is still unclear.

Evidence synthesis and guideline groups have the potential to address health disparities. In June 2024, the Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson Foundation (RWJF) cosponsored a summit to address racial and ethnic health equity in systematic reviews and other syntheses and guidelines, with support from Cochrane US. This article summarizes cross-cutting themes around future directions for systematic reviews and guidelines. Discussions addressed include the rationale for addressing racial health equity in systematic reviews and guidelines; representation of people with lived experience in systematic reviews and guidelines; approaches to developing and addressing equity-focused scope, including frameworks, methods, and thoughtful interpretation in systematic reviews; challenges and opportunities for guideline recommendations; need for standardized language and reporting for race and ethnicity in primary research studies, systematic reviews, and guidelines; and measures to track the progress of incorporating and addressing racial and ethnic health equity in systematic reviews and guidelines. Participants acknowledged that a one-size-fits-all approach was not possible or desired. Consensus priorities for next steps were to develop methods guidance to address equity in systematic reviews and guidelines; develop measures to track the progress of addressing racial and health equity in systematic reviews and guidelines; operationalize engaging representative interest holders in systematic reviews and guidelines; and share resources and learning for advancing health equity.

Racial and ethnic health equity is the absence of unfair and avoidable or remediable differences in health and well-being among persons belonging to different racial and ethnic groups. This article summarizes current guidance and identifies practices for systematic reviewers and guideline groups to develop clinical practice guidelines that mitigate such inequities. Current guidance recommends that systematic reviews and clinical practice guidelines ensure a wider perspective; identify, prioritize, and develop equity-focused topics and questions; and apply specific methods and processes to answer equity-focused questions. Ensuring a wider perspective involves incorporating persons with lived experiences and other relevant nonclinical expertise into review and guideline teams as well as engagement of patients and members of affected populations in the review and guideline process. Examples for identifying and developing equity-focused topics and questions include using health equity as a criterion to select and prioritize topics, developing topics specific to mitigating racial and ethnic health inequities, and addressing upstream drivers of inequities and implementation considerations. Appropriate methods and processes might include considering different types of study designs, selecting the type of review accordingly, and using suitable evidentiary frameworks and thresholds to answer a broader set of equity-relevant questions. Several review, health technology assessment, guideline, and other health care decision-maker groups are implementing guidance to address racial and ethnic health equity.

Patients with irritable bowel syndrome (IBS) frequently seek dietary advice, but few evidence-based options exist. Major societal guidelines recommend traditional dietary advice (TDA) as first-line therapy, with the cumbersome and resource-intensive low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet reserved as second-line therapy. Recent pilot data suggest that the Mediterranean diet (MD), renowned for its general health benefits, improves IBS symptoms, but whether it can be considered another first-line dietary option is unknown.

Although physical activity recommendations increasingly consider daily step counts, it remains unclear whether step accumulation patterns-short versus sustained longer bouts-affect associations with mortality and cardiovascular disease (CVD) among suboptimally active populations.

Clinical practice guidelines (CPGs) may not consistently address racial and ethnic health equity (RHE). This article discusses an audit of CPGs in the ECRI Guidelines Trust (EGT) aiming to summarize the extent and context in which CPGs address RHE, determine use of race-based recommendations, and determine inclusion of patient or public perspectives representing a racially or ethnically diverse group. A working group searched the EGT from 1 January 2020 to 31 January 2025 using RHE-related terms. They included CPGs that were developed by a U.S. organization in an adult population and underpinned by a systematic review that used RHE-related terms. They reviewed included CPGs and their supporting materials, extracted key characteristics, and narratively summarized key findings. The working group identified 137 full-text CPGs. Of these, 105 explicitly addressed RHE terms, whereas the remainder discussed equity or disparities more broadly. When explicitly addressed, RHE was most commonly included as part of the implementation considerations or in the discussion (78.1%). When incorporated into the conduct or methods of developing a guideline recommendation (64.7%), RHE was addressed in the search (8.8%), methods (33.8%), results (41.1%), or EtD or recommendation (39.7%). Although none of the guidelines included a race-based recommendation, 22.8% identified RHE evidence gaps. In total, 84.7% described racial and/or ethnic disparities in the clinical condition and 20% explicitly stated that race is a social construct. Only 3.3% expressly incorporated a racially or ethnically diverse patient or public perspective. However, the search was limited to the EGT, and search terms may not represent the full scope of RHE. Among CPGs addressing health equity, explicit consideration of RHE is mostly addressed in implementation considerations, with less incorporation into the methods or guideline recommendation.

Recent developments and controversies in organ transplantation necessitate the reaffirmation and application of foundational ethical norms as the laudable goal of increasing viable organs for transplantation is pursued. The physician's primary duties are to individual patients under the physician's care. For physicians of prospective donor-patients, the "bright line" between serving the best interests of donor-patients and their families and serving potential recipient-patients and the public interest can become blurred in ethically problematic ways. This paper provides ethical guidance for clinicians involved in organ transplantation as well as for patients, families, the public, policymakers, and others to help maintain trust and encourage participation in this life-saving enterprise. It clarifies the duties and roles of care teams of prospective donor-patients, recipient-patients, and organ procurement teams, reaffirming that end-of-life decision making for prospective donor-patients must center on the best interests of donor-patients and their families independent of organ donation potential. It also emphasizes the importance of truly informed consent for organ donation and advocates for prioritizing equity and transparency in transplantation processes.

Systematic reviews and other evidence synthesis products support clinical practice guidelines, policy and coverage decisions, and future research directions. These products can help promote health equity by examining why differences in outcomes exist, how underrepresentation or overrepresentation in the evidence affects generalizability, and how to address underlying societal sources of disparities. This article provides an overview of and background for a series of articles sponsored by the Agency for Healthcare Research and Quality and the Robert Wood Johnson Foundation. The series focuses on racial and ethnic health equity as one approach to enhance the utility of systematic reviews in addressing inequities. Together, the articles in the series address what end users of systematic reviews, specifically guideline developers, have done thus far; how best to methodologically address racial health equity; and what steps to take next.

Cardiac implantable electronic devices (CIEDs) have increased the quality and duration of life for millions of patients. As their utilization continues to grow exponentially, clinicians need to diagnose and manage several device-associated complications that may arise during the CIED life cycle. This primer is tailored for the general internal medicine physician or hospitalist, who will inevitably take care of patients with CIEDs, to provide a contemporary update on the incidence and clinical manifestations of the 4 most common CIED complications, with the latest evidence to guide clinical management and expected outcomes. Specifically, this review focuses on: 1) generator/lead failure, which has decreased to less than 1% per year due to continuous advances in manufacturing and programming and is mostly managed conservatively with close monitoring; 2) CIED infections, which, while also rare at approximately 1% per year, carry a short-term mortality of 10% to 20%, thus requiring immediate diagnosis and often urgent treatment with lead extraction because antibiotic treatment is rarely effective; and 3) lead-related venous obstruction, which has highly variable incidence (5% to 30%) and manifestations, ranging from arm swelling to superior vena cava syndrome. Management options range from anticoagulation to balloon venoplasty, often with unsatisfying results. This review will also focus on 4) lead-related tricuspid regurgitation, which affects 20% to 30% of CIEDs and has become an area of intense interest with the development of percutaneous tricuspid treatments-where evidence is urgently needed to inform the need for lead extraction versus jailing during tricuspid interventions. The progressive adoption of leadless devices may significantly reduce many of these complications. Nonetheless, optimal management requires input from a multidisciplinary team of electrophysiologists and imaging, heart failure, and structural interventional specialists-who should be able to recognize and treat each complication promptly based on a rapidly evolving evidence base.

Colorectal cancer is the second leading cause of cancer-related deaths for both men and women. Screening for colorectal cancer is an effective strategy to reduce morbidity and mortality, but uptake remains suboptimal. Several performance measures for colorectal cancer screening and surveillance are currently used in pay-for-performance, public reporting, and/or accountability programs. The American College of Physicians (ACP) embraces performance measurement as a means to improve quality of care. The ACP believes that a performance measure must be methodologically sound and evidence-based to be considered for inclusion in payment, accountability, or reporting programs. These principles are critical given the potential effect to physician administrative work and reputation and reimbursement and to prevent unintended consequences on patient care. The ACP's Performance Measurement Committee (PMC) reviews performance measures using a validated process to recognize high-quality performance measures, address gaps and areas for improvement in performance measures, and help reduce reporting burden. This article aims to present a review of current performance measures for colorectal cancer screening and surveillance to inform physicians, payers, and policymakers in their selection and use of performance measures and make recommendations for measures that could be developed. The PMC appreciates the importance of colorectal cancer screening in the prevention and early detection of colorectal cancer and supports performance measures based on strong recommendations. The PMC reviewed 5 performance measures for colorectal cancer screening relevant to internal medicine and supports 1 performance measure ("Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy") for use.

There is concern about widespread increases in cancer incidence rates in younger adults.

Given a marked expansion in the work of primary care in recent decades, it is critical to have an accurate understanding of the time involved in managing a primary care panel and the determinants of this time.

Chronic coronary artery disease (CCAD) is a leading cause of death in the United States and many other countries. The defining pathobiology is an imbalance between the metabolic demands of the myocardium and oxygen supply, which most often results from coronary artery atherosclerosis. The classic presenting symptom of CCAD is angina, but clinical presentation varies greatly among patients. Since the last In the Clinic on CCAD (previously termed "stable ischemic heart disease") in 2019, several new medications have been approved to reduce ischemic complications.

Recombinant zoster vaccine (RZV) was preferentially recommended over live zoster vaccine (ZVL) starting in 2018.

Breast cancer is the second leading cause of cancer death among women in the United States. Screening mammography, which aims to detect asymptomatic breast cancers at earlier and more intervenable stages, has reduced breast cancer mortality, but not overall mortality, in randomized trials. As of 2024, the U.S. Preventive Services Task Force now recommends biennial screening mammography for women aged 40 to 74 years (grade B recommendation). In these rounds, 2 experts, the first a primary care physician and member of the Task Force and the second an epidemiologist and family practitioner, debate this recommendation in the context of Ms. R, a 39-year-old woman. They discuss the benefits and harms of breast cancer screening, the ideal age and frequency at which to conduct screening, and the key points to include when having a conversation with a patient about breast cancer screening.

GIM/FP/GP: [Formula: see text] Endocrinology: [Formula: see text].

Exposure to the 1918 influenza pandemic may have been associated with preterm birth (<37 weeks). Other outcomes, such as infant size or weight, have rarely been explored. Using 2177 historical birth records from University Maternity Hospital of Lausanne, it was estimated whether in utero exposure to maternal influenza-like illness (ILI) during the 1918 pandemic was associated with pregnancy outcomes and whether associations varied depending on the trimester of ILI during pregnancy or on fetal sex. Generalized linear models and robust linear models were used to analyze the association between ILI and gestational age, stillbirth, and anthropometric measurements, adjusting on covariates. Analyses were stratified by fetal sex. A total of 282 (13%) women developed ILI during pregnancy. Exposure to ILI was associated with lower anthropometric measurements: low birthweight (LBW; <2500 g) (marginally adjusted percentage was 13.3% compared with 6.9% in the unexposed group; difference, 6.4 percentage points [95% CI, 5.5 to 7.2 percentage points]). There was strong evidence that third trimester exposure was associated with worse adverse pregnancy outcomes, including with LBW (difference, 12.8 percentage points [CI, 11.8 to 13.7 percentage points]) and preterm birth rates (difference, 9.4 percentage points [CI, 8.2 to 10.6 percentage points]). Maternal ILI may have triggered premature birth. The magnitude of the declines in anthropometric parameters was higher among male fetuses, and they had a higher stillbirth rate. For instance, males exposed during the third trimester had their birthweight lowered by 228.4 g (CI, -391.0 to -65.8 g) compared with 126.3 g among females [CI, -256.6 to 4.0 g]. Only 41% of infants exposed to first-trimester ILI were males, suggesting a selection against male fetuses through miscarriage. Our findings may not generalize to the entire population of Lausanne, as 34% of births were home births at the time.

GIM/FP/GP: [Formula: see text] Endocrinology: [Formula: see text].

Users of GRADE (Grading of Recommendations Assessment, Development and Evaluation) make judgments about the size of intervention effects on desirable and undesirable people-important health outcomes or on benefits and harms. Benchmarking effect sizes by using decision thresholds (DTs) can help to facilitate these judgments and the process. This article provides GRADE guidance for use of DTs for judgments about the magnitude of desirable and undesirable health effects, such as in a health guideline or health technology assessment. Through iterative discussions and refinement in in-person and online meetings of a GRADE project group and through e-mail communication, the authors developed guidance for using DTs in Evidence-to-Decision (EtD) frameworks. The authors applied the approach and used these examples from guidelines and the results of a randomized methodological study to develop official GRADE guidance. Several alternatives for determining and using DTs are presented. In the first main approach, outcome-specific DTs for trivial, small, moderate, and large effects are determined through a calculation using empirically derived generic coefficients and the outcome's utility value and are compared with the effect estimate obtained from an evidence synthesis. In the second main approach, outcome-specific DTs are also determined, but through direct surveying of decision makers to explicitly assign thresholds for the prioritized health outcomes. The article also describes how these approaches can be combined. The suggested approaches provide transparency for judgments in EtD frameworks that are based on findings from evidence syntheses.

Emergency Med: [Formula: see text] GIM/FP/GP: [Formula: see text] Neurology: [Formula: see text].