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. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
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1. Low-carb diet may help patients with diabetes achieve better weight loss and glucose control in short term compared to a low-fat diet
Abstract: https://www.acpjournals.org/doi/10.7326/M22-1787
URL goes live when the embargo lifts
A randomized controlled trial of more than 100 persons with type 2 diabetes found that a low-carbohydrate, high-fat, calorie unrestricted diet helped patients achieve better weight loss and glucose control over a 6-month intervention compared to a high-carb, low-fat diet. The changes were not sustained 3 months after the intervention, suggesting a need for long-term dietary changes to maintain meaningful health benefits. The findings are published in Annals of Internal Medicine.
More than 480 million people worldwide are affected by type 2 diabetes. More than half of persons with diabetes also have nonalcoholic fatty liver disease (NAFLD), which can progress to cirrhosis and impair liver function. Prior studies suggest that weight loss improves both diabetes control and NAFLD and restriction of carbohydrate intake improves the control of blood sugar levels.
Researchers from the University of Southern Denmark, Odense, Denmark, randomly assigned 165 persons with type 2 diabetes to either a LCHF diet or a HCLF diet for 6 months. Participants in both groups were asked to eat the same number of calories equal to their energy expenditure. Participants on the low carb diet were asked to eat no more than 20% of their calories from carbohydrates but could have 50- 60% of their calories from fat and 20-30% from protein. Patients on the low-fat diet were asked to eat about half of their calories in carbohydrates and the rest evenly split between fats and proteins. The authors found that persons on the low carb diet reduced hemoglobin A1c by 0.59 percent more than the low-fat diet, and also lost 3.8 kg more weight compared to those in the low-fat group. The low carb dieters also lost more body fat and reduced their waist circumference. Both groups had higher high-density lipoprotein cholesterol and lower triglycerides at 6 months. However, changes were not sustained 3 months after the intervention, suggesting that dietary changes need to be sustained over the long term to maintain effects. The liver was not affected by the high fat intake in the low-carb group: The researchers found no difference on the amount of liver fat or inflammation between the two groups.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Aleksander Krag, MD, PhD, please email Camila Dalby Hansen at Camilla.Dalby.Hansen@rsyd.dk.
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2. Nirmatrelvir plus ritonavir may reduce risk for hospitalization or death from COVID-19
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2141
URL goes live when the embargo lifts
A retrospective cohort study of more than 44,000 nonhospitalized persons diagnosed with COVID-19 found that nirmatrelvir plus ritonavir reduced the overall risk of hospitalization and death. The study is published in Annals of Internal Medicine.
In the EPIC-HR (Evaluation of Protease Inhibition for Covid-19 in High-Risk Patients) trial, nirmatrelvir plus ritonavir led to an 89% reduction in hospitalization or death among unvaccinated outpatients with early COVID-19. The World Health Organization recommended nirmatrelvir plus ritonavir in April 2022, but only for the highest-risk persons and advised against use in most vaccinated and other lower-risk persons. The clinical impact of nirmatrelvir plus ritonavir among vaccinated populations is uncertain.
Researchers from Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health studied 44,551 nonhospitalized persons with COVID-19 aged 50 years or older in the Mass General Brigham healthcare system to assess whether nirmatrelvir plus ritonavir could reduce the risk for hospitalization or death in the setting of prevalent SARS-CoV-2 immunity and immune-evasive SARS-CoV-2 lineages. More than 90% of participants had at least 3 vaccine doses at the time of the study. During the study period, 28.1% of participants received nirmatrelvir plus ritonavir and 71.9% did not. The authors found that recipients of nirmatrelvir plus ritonavir had 40% lower risk for hospitalization and 71% lower risk of death, although the risk for either was already very low (less than 1%). Overall, the mortality rate among persons prescribed nirmatrelvir plus ritonavir was 0.55% and 0.97% among persons who were not. The authors note that among those who were diagnosed as outpatients, Black, Hispanic, or Latinx patients had much lower rates of prescription of nirmatrelvir plus ritonavir. To realize the public health potential of outpatient COVID-19 therapy, clinicians must address this gap and these disparities.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Scott Dryden-Peterson, MD, MSc, please contact Mark Murphy at mmurphy90@bwh.harvard.edu.
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3. Early engagement with affected communities helped to control mpox outbreak in Montreal
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2699
URL goes live when the embargo lifts
An analysis of the first large mpox outbreak in North America found that early, sustained engagement and rapid offering of preexposure vaccination to affected communities successfully controlled the spread of the outbreak. The analysis is published in Annals of Internal Medicine.
Mpox is historically endemic to west and central Africa but spread significantly in other countries in 2022, primarily among the men who have sex with men (MSM) community. During this time, Montreal, Quebec, Canada, emerged as the site of the first large outbreak in North America.
Researchers from McGill University Health Centre, Montreal, Canada characterized and analyzed the epidemiologic, clinical, and demographic data from 402 persons with probable or confirmed cases of mpox in Montreal and the public health response by Montreal Public Health. The authors report that Montreal experienced its initial mpox outbreak in May 2022, followed by two peaks in early June and early July. This was followed by a decline in cases. Nearly all reported cases were among MSM who likely acquired the infection through sexual contact. Montreal public health authorities acted quickly to lead interventions to control the transmission. These interventions included early and sustained engagement with the affected communities; alerting clinicians to promote rapid case detection and reporting; performing case investigation and contact tracing; and contributing to the development of interim guidance on diagnostic testing, case and contact management, and recommended infection and control prevention measures. According to the authors, the prompt recognition of the importance of preexposure vaccination in at-risk populations and the extended offer of MVA-BN to tourists coming to Montreal led to many being vaccinated. They add that increasing and supporting equitable access to vaccines for at-risk populations worldwide should be a global priority for the prevention and control of mpox.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Sapha Barkati, MD, MSc, email sapha.barkati2@mcgill.ca.
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4. Physicians discuss strategies for managing chronic insomnia
All Beyond the Guidelines discussions are based on Grand Rounds from Beth Israel Deaconess Medical Center
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2817
URL goes live when the embargo lifts
In a new Annals ‘Beyond the Guidelines,’ a clinical psychologist and sleep physician debate the management of a patient with chronic insomnia who has been treated with medications. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.
Insomnia, which is characterized by persistent sleep difficulties in association with daytime dysfunction, is a common concern in clinical practice. Chronic insomnia disorder is defined as symptoms that occur at least 3 times per week and persist for at least 3 months. Recent guidelines published by the American Academy of Sleep Medicine (AASM) recommended multicomponent cognitive behavioral therapy (CBT) and a limited number of medications that might be useful for insomnia.
BIDMC Grand Rounds discussants, Eric S. Zhou, PhD, an Assistant Professor at Harvard Medical School and a clinical psychologist at Dana-Farber Cancer Institute, and Eric Heckman, MD, an Instructor at Harvard Medical School and sleep specialist and pulmonologist at Beth Israel Deaconess Medical Center, discuss the case of a 64-year-old man who experienced difficulty getting to sleep and early morning awakening for decades. The patient was prescribed zolpidem many years ago, which was initially taken as needed but now is a daily necessity to get to sleep. More recently, trazodone was added to his regimen. The patient has also been diagnosed with obstructive sleep apnea (OSA).
In their assessment, both Drs. Zhou and Heckman agree that CBT is the preferred intervention in the patient’s situation. Dr. Heckman would first evaluate and treat the patient for OSA and other comorbid conditions such as restless leg syndrome that might affect his sleep, while Dr. Zhou would dispel the commonly held belief that patients all require 8 hours of sleep per night as part of his treatment. Dr. Zhou and Mr. F would also collaborate on identifying his individual sleep need through a structured process involving sleep restriction and, subsequently, expansion. Dr. Heckman would consider a streamlined, clinic-based behavioral intervention focusing on sleep restriction and stimulus control if CBT was not accessible or acceptable to the patient. He would not insist on discontinuation of medications immediately but would attempt to stop trazodone followed by reduction in the dose of zolpidem over time as tolerated.
A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. For an interview with the discussants, please contact Kendra McKinnon at Kmckinn1@bidmc.harvard.edu.
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Also new in this issue:
Monoclonal Gammopathy of Undetermined Significance
Wilson I. Gonsalves, MD; S. Vincent Rajkumar, MD
In the Clinic
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2016
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