Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.
1. Firearms, by far, the most lethal method for suicide
Prevention efforts focused on reducing access to firearms could save lives
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Variation in overall suicide case-fatality rates between sexes and across age groups, regions, and urbanization is largely explained by suicide method. By far, firearms are the most lethal method, with 9 out of 10 attempts being fatal. The overall fatality rate for suicide attempts nationwide is 1 out of 12. Findings from a nationwide population-based study are published in Annals of Internal Medicine.
Suicide was the 10th leading cause of death in the U.S. in 2017. The method used to attempt suicide determines the frequency and distribution of fatal and nonfatal suicidal behavior across demographic groups.
Researchers from Frank H. Netter MD School of Medicine at Quinnipiac University, Harvard Injury Control Research Center at the Harvard T.H. Chan School of Public Health, and Northeastern University, Bouve´ College of Health Sciences used publicly available national records to estimate overall and method-specific suicide case-fatality rates and the distribution of methods used in suicidal acts by demographic characteristics. They found that overall, 8.5 percent of suicide attempts were fatal. Firearms were the most lethal method, with nearly 90 percent of attempts resulting in death, but were one of the least common methods of suicidal acts. Drowning and hanging had the next highest case-fatality rates. Drug poisoning accounted for nearly 60 percent of suicide acts, but only 2 percent of attempts were fatal. Method-specific case-fatality rates were higher for males and older persons and the distribution of methods varied across demographic groups. According to the study authors, these findings suggest that prevention approaches aimed at reducing access to firearms could save lives.
2. Untreated gout may lead to myocarditis and heart failure
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Treatment with allopurinol and steroids alleviated symptoms of gouty myocarditis
Gout can be associated with myocarditis with cardiac dilatation, cardiac dysfunction, and heart failure, particularly in patients with untreated gout and high levels of uric acid crystals, clinicians conclude in a Case Report published in Annals of Internal Medicine.
Myocarditis, a condition characterized by inflammation of the heart muscle, is an important cause of heart failure. Gout is a metabolic disorder characterized by increased uric acid in the blood and deposits of urate crystals that cause a vigorous inflammatory reaction in the joints, kidneys, and soft tissues. Urate crystals have been found in coronary vessels and cardiac valves but not, according to the researchers, in the myocardium.
Clinicians from IRCCS, Lazzaro Spallanzani observed a 49-year-old man with severe gouty arthritis in multiple joints and soft tissue tophi (uric acid crystals). He had stopped taking allopurinol (to treat gout) and colchicine (to decrease swelling and lessen the buildup of uric acid crystals) for several months because of gastric discomfort and diarrhea. The patient's echocardiogram showed biventricular dilatation with a left ventricular ejection fraction of 30 percent and a right ventricular ejection fraction of 39 percent. Histology revealed extensive myocarditis with inflammatory infiltrates. Electron microscopy found amorphous crystals.
The clinicians treated the patient with allopurinol (300 mg/d) and prednisone (1 mg/kg of body weight daily). After four weeks of treatment, his cardiovascular condition improved and his left ventricular ejection fraction measured with 2-dimensional echocardiography had increased from 30 to 45 percent. Researchers hypothesize that gout may lead to myocarditis when amorphous urate crystal deposits inside cardiac muscle cells, inducing a strong inflammatory reaction and cell death.
3. Performance of STOP HCC screening intervention varied widely across safety net practices
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In view of highly effective, curative treatment for hepatitis C virus (HCV), the U.S. Preventive Services Task Force recommends one-time HCV screening for all persons born in 1945 through 1965 (baby boomers). Yet adoption of these recommendations has lagged nationally. The Screen, Treat, Or Prevent Hepatocellular Carcinoma (STOP HCC) intervention for hepatitis C virus (HCV) aimed to promote HCV screening and management of chronic HCV in safety-net primary care practices serving majority-Hispanic communities that have significant morbidity and mortality from liver disease. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model informed implementation of a multicomponent intervention to screen and treat HCV. Despite similar infrastructure for STOP HCC implementation, a mixed-methods analysis revealed wide variations in performance across these practices. Differences in screening rates may reflect practice engagement as well as structural and cost challenges beyond practice control. The STOP HCC model and an examination of factors contributing to these performance variations are published in Annals of Internal Medicine.
Researchers from the University of Texas Health Science Center at San Antonio partnered with five federally qualified health care (FQHC) systems and a family medicine residency program to implement HCV screening in never-tested baby boomers and with four FQHCs to manage and treat uninsured patients diagnosed with chronic HCV infection. Prior to STOP HCC, screening baby boomers for HCV was virtually nonexistent but increased to 48 percent of 27,700 eligible baby boomers over a period of 29 to 43 months. Yet the screening rates varied by practice from 19.8 percent to 71.3 percent of eligible patients. Of all 205 uninsured baby boomers diagnosed with chronic HCV in four FQHCs, 174 (84.9 percent) completed disease staging but only 74 (36.1 percent) completed HCV treatment, ranging from 27.8 to 60.0 percent by practice. Of these completers, 70 (94.9 percent) patients achieved a cure. These findings suggest that a need for policies and payment systems to promote HCV screening and management more uniformly across practices serving low-income Hispanic communities that are significantly affected by liver disease.
Media contacts: For embargoed PDFs please contact Lauren Evans at Laevans@acponline.org. To speak with the lead author, Barbara Turner, MD, MSEd, please contact her directly at Barbara.Turner@med.usc.edu.
Also new in this issue:
Should This Patient Be Screened for Atrial Fibrillation? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Risa B. Burns, MD, MPH; Peter Zimetbaum, MD; Steven A. Lubitz, MD, MPH; and Gerald W. Smetana, MD
Beyond the Guidelines
Obstructive Sleep Apnea
Sanjay R. Patel, MD, MS
In the Clinic