The Cost of Lack of Health Insurance

Joint Letter to FDA in Support of Banning Use of Menthol in Tobacco Products

ACP's Response to the GOP SGR Framework Proposal as Released by the Ways & Means and Energy & Commerce Committees

Coalition Letter Opposing EPA's Proposed Reconsideration of the 2009 Endangerment Finding and Greenhouse Gas Vehicle Standards

Racial and Ethnic Disparities in Healthcare

Principles Supporting Clinical Care Teams

Patient-Centered, Physician-Guided Care for the Chronically Ill: The American College of Physicians Prescription for Change

Direct to Consumer Prescription Drug Advertising

ACP Comments on 2022 Physician Fee Schedule and Quality Payment Program Proposed Rule

Strengthening the Public Health Infrastructure

2022 Clinical Practice Guideline Update for Diabetes Management of Chronic Kidney Disease: An Important First Step, More Work to Do

Prevalence and Management of Obesity in U.S. Adults With Type 1 Diabetes

Primary Occurrence of Cardiovascular Events After Adding Sodium–Glucose Cotransporter-2 Inhibitors or Glucagon-like Peptide-1 Receptor Agonists Compared With Dipeptidyl Peptidase-4 Inhibitors: A Cohort Study in Veterans With Diabetes

Background: The effectiveness of glucagon-like peptide-1 receptor agonists (GLP1RA) and sodium–glucose cotransporter-2 inhibitors (SGLT2i) in preventing major adverse cardiac events (MACE) is uncertain for those without preexisting cardiovascular disease. Objective: To test the hypothesis that MACE incidence was lower with the addition of GLP1RA or SGLT2i compared with dipeptidyl peptidase-4 inhibitors (DPP4i) for primary cardiovascular prevention. Design: Retrospective cohort study of U.S. veterans from 2001 to 2019. Setting: Veterans aged 18 years or older receiving care from the Veterans Health Administration, with data linkage to Medicare, Medicaid, and the National Death Index. Patients: Veterans adding GLP1RA, SGLT2i, or DPP4i onto metformin, sulfonylurea, or insulin treatment alone or in combination. Episodes were stratified by history of cardiovascular disease. Measurements: Study outcomes were MACE (acute myocardial infarction, stroke, or cardiovascular death) and heart failure (HF) hospitalization. Cox models compared the outcome between medication groups using pairwise comparisons in a weighted cohort adjusted for covariates. Results: The cohort included 28 759 GLP1RA versus 28 628 DPP4i weighted pairs and 21 200 SGLT2i versus 21 170 DPP4i weighted pairs. Median age was 67 years, and diabetes duration was 8.5 years. Glucagon-like peptide-1 receptor agonists were associated with lower MACE and HF versus DPP4i (adjusted hazard ratio [aHR], 0.82 [95% CI, 0.72 to 0.94]), yielding an adjusted risk difference (aRD) of 3.2 events (CI, 1.1 to 5.0) per 1000 person-years. Sodium–glucose cotransporter-2 inhibitors were not associated with MACE and HF (aHR, 0.91 [CI, 0.78 to 1.08]; aRD, 1.28 [−1.12 to 3.32]) compared with DPP4i. Limitation: Residual confounding; use of DPP4i, GLP1RA, and SGLT2i as first-line therapies were not examined. Conclusion: The addition of GLP1RA was associated with primary reductions of MACE and HF hospitalization compared with DPP4i use; SGLT2i addition was not associated with primary MACE prevention. Primary Funding Source: VA Clinical Science Research and Development and supported in part by the Centers for Diabetes Translation Research.

Comparative Effectiveness of Team-Based Care With and Without a Clinical Decision Support System for Diabetes Management: A Cluster Randomized Trial: Annals of Internal Medicine: Vol 176, No 1

Background: Uncontrolled hyperglycemia, hypercholesterolemia, and hypertension are common in persons with diabetes. Objective: To compare the effectiveness of team-based care with and without a clinical decision support system (CDSS) in controlling glycemia, lipids, and blood pressure (BP) among patients with type 2 diabetes. Design: Cluster randomized trial. (ClinicalTrials.gov: NCT02835287) Setting: 38 community health centers in Xiamen, China. Patients: 11 132 persons aged 50 years or older with uncontrolled diabetes and comorbid conditions, 5475 receiving team-based care with a CDSS and 5657 receiving team-based care alone. Intervention: Team-based care was delivered by primary care physicians, health coaches, and diabetes specialists in all centers. In addition, a computerized CDSS, which generated individualized treatment recommendations based on clinical guidelines, was implemented in 19 centers delivering team-based care with a CDSS. Measurements: Coprimary outcomes were mean reductions in hemoglobin A1c (HbA1c) level, low-density lipoprotein cholesterol (LDL-C) level, and systolic BP over 18 months and the proportion of participants with all 3 risk factors controlled at 18 months. Results: During the 18-month intervention, HbA1c levels, LDL-C levels, and systolic BP significantly decreased by −0.9 percentage point (95% CI, −0.9 to −0.8 percentage point), −0.49 mmol/L (CI, −0.53 to −0.45 mmol/L) (−19.0 mg/dL [CI, −20.4 to −17.5 mg/dL]), and −9.1 mm Hg (CI, −9.9 to −8.3 mm Hg), respectively, in team-based care with a CDSS and by −0.6 percentage point (CI, −0.7 to −0.5 percentage point), −0.32 mmol/L (CI, −0.35 to −0.29 mmol/L) (−12.5 mg/dL [CI, −13.6 to −11.3 mg/dL]), and −7.5 mm Hg (CI, −8.4 to −6.6 mm Hg), respectively, in team-based care alone. Net differences were −0.2 percentage point (CI, −0.3 to −0.1 percentage point) for HbA1c level, −0.17 mmol/L (CI, −0.21 to −0.12 mmol/L) (−6.5 mg/dL [CI, −8.3 to −4.6 mg/dL]) for LDL-C level, and −1.5 mm Hg (CI, −2.8 to −0.3 mm Hg) for systolic BP. The proportion of patients with controlled HbA1c, LDL-C, and systolic BP was 16.9% (CI, 15.7% to 18.2%) in team-based care with a CDSS and 13.0% (CI, 11.7% to 14.3%) in team-based care alone. Limitation: There was no usual care control, and clinical outcome assessors were unblinded; the analysis did not account for multiple comparisons. Conclusion: Compared with team-based care alone, team-based care with a CDSS significantly reduced cardiovascular risk factors in patients with diabetes, but the effect was modest. Primary Funding Source: Xiamen Municipal Health Commission.

Effect of Calorie-Unrestricted Low-Carbohydrate, High-Fat Diet Versus High-Carbohydrate, Low-Fat Diet on Type 2 Diabetes and Nonalcoholic Fatty Liver Disease: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 176, No 1

Background: It remains unclear if a low-carbohydrate, high-fat (LCHF) diet is a possible treatment strategy for type 2 diabetes mellitus (T2DM), and the effect on nonalcoholic fatty liver disease (NAFLD) has not been investigated. Objective: To investigate the effect of a calorie-unrestricted LCHF diet, with no intention of weight loss, on T2DM and NAFLD compared with a high-carbohydrate, low-fat (HCLF) diet. Design: 6-month randomized controlled trial with a 3-month follow-up. (ClinicalTrials.gov: NCT03068078) Setting: Odense University Hospital in Denmark from November 2016 until June 2020. Participants: 165 participants with T2DM. Intervention: Two calorie-unrestricted diets: LCHF diet with 50 to 60 energy percent (E%) fat, less than 20E% carbohydrates, and 25E% to 30E% proteins and HCLF diet with 50E% to 60E% carbohydrates, 20E% to 30E% fats, and 20E% to 25E% proteins. Measurements: Glycemic control, serum lipid levels, metabolic markers, and liver biopsies to assess NAFLD. Results: The mean age was 56 years (SD, 10), and 58% were women. Compared with the HCLF diet, participants on the LCHF diet had greater improvements in hemoglobin A1c (mean difference in change, −6.1 mmol/mol [95% CI, −9.2 to −3.0 mmol/mol] or −0.59% [CI, −0.87% to −0.30%]) and lost more weight (mean difference in change, −3.8 kg [CI, −6.2 to −1.4 kg]). Both groups had higher high-density lipoprotein cholesterol and lower triglycerides at 6 months. Changes in low-density lipoprotein cholesterol were less favorable in the LCHF diet group than in the HCLF diet group (mean difference in change, 0.37 mmol/L [CI, 0.17 to 0.58 mmol/L] or 14.3 mg/dL [CI, 6.6 to 22.4 mg/dL]). No statistically significant between-group changes were detected in the assessment of NAFLD. Changes were not sustained at the 9-month follow-up. Limitation: Open-label trial, self-reported adherence, unintended weight loss, and lack of adjustment for multiple comparisons. Conclusion: Persons with T2DM on a 6-month, calorie-unrestricted, LCHF diet had greater clinically meaningful improvements in glycemic control and weight compared with those on an HCLF diet, but the changes were not sustained 3 months after intervention. Primary Funding Source: Novo Nordisk Foundation.

Diabetes Screening: Different Thresholds for Different Racial/Ethnic Groups

Paternal Preconception Diabetes Drugs and Birth Defects in Offspring: A Call for More Conclusive Study

The National Clinical Care Commission Report: Improving Federal Programs That Impact Diabetes Prevention and Care

Cardiovascular Outcomes in Patients Initiating First-Line Treatment of Type 2 Diabetes With Sodium–Glucose Cotransporter-2 Inhibitors Versus Metformin: A Cohort Study: Annals of Internal Medicine: Vol 175, No 7

Background: Evidence on the risk for cardiovascular events associated with use of first-line sodium–glucose cotransporter-2 inhibitors (SGLT-2i) compared with metformin is limited. Objective: To assess cardiovascular outcomes among adults with type 2 diabetes (T2D) who initiated first-line treatment with SGLT-2i versus metformin. Design: Population-based cohort study. Setting: Claims data from 2 large U.S. commercial and Medicare databases (April 2013 to March 2020). Participants: Patients with T2D aged 18 years and older (>65 years in Medicare) initiating treatment with SGLT-2i or metformin during April 2013 to March 2020, without any use of antidiabetic medications before cohort entry, were identified. After 1:2 propensity score matching in each database, pooled hazard ratios (HRs) and 95% CIs were reported. Intervention: First-line SGLT-2i (canagliflozin, empagliflozin, or dapagliflozin) or metformin. Measurements: Primary outcomes were a composite of hospitalization for myocardial infarction (MI), hospitalization for ischemic or hemorrhagic stroke or all-cause mortality (MI/stroke/mortality), and a composite of hospitalization for heart failure (HHF) or all-cause mortality (HHF/mortality). Safety outcomes including genital infections were assessed. Results: Among 8613 first-line SGLT-2i initiators matched to 17 226 metformin initiators, SGLT-2i initiators had a similar risk for MI/stroke/mortality (HR, 0.96; 95% CI, 0.77 to 1.19) and a lower risk for HHF/mortality (HR, 0.80; CI, 0.66 to 0.97) during a mean follow-up of 12 months. Initiators receiving SGLT-2i showed a lower risk for HHF (HR, 0.78; CI, 0.63 to 0.97), a numerically lower risk for MI (HR, 0.70; CI, 0.48 to 1.00), and similar risk for stroke, mortality, and MI/stroke/HHF/mortality compared with metformin. Initiators receiving SGLT-2i had a higher risk for genital infections (HR, 2.19; CI, 1.91 to 2.51) and otherwise similar safety as those receiving metformin. Limitation: Treatment selection was not randomized. Conclusion: As first-line T2D treatment, initiators receiving SGLT-2i showed a similar risk for MI/stroke/mortality, lower risk for HHF/mortality and HHF, and a similar safety profile except for an increased risk for genital infections compared with those receiving metformin. Primary Funding Source: Brigham and Women's Hospital and Harvard Medical School.

Diabetes-Related Complications and Mortality in Patients With Atrial Fibrillation Receiving Different Oral Anticoagulants: A Nationwide Analysis: Annals of Internal Medicine: Vol 175, No 4

Background: Evidence about the association between types of oral anticoagulants and hazards of diabetes complications is limited in patients with atrial fibrillation (AF) and diabetes mellitus (DM). Objective: To compare the hazards of diabetes complications and mortality between patients with AF and DM receiving non–vitamin K antagonist oral anticoagulants (NOACs) and those receiving warfarin. Design: A retrospective cohort study. Setting: Nationwide data obtained from Taiwan's National Health Insurance Research Database. Patients: Patients with AF and DM receiving NOACs or warfarin between 2012 and 2017 in Taiwan were enrolled. Treatment groups were determined by patients' first initiation of oral anticoagulants. Measurements: Hazards of diabetes complications (macrovascular complications, microvascular complications, and glycemic emergency) and mortality in the NOAC and warfarin users were investigated with a target trial design. Cause-specific Cox proportional hazards models were used to estimate hazard ratios (HRs). Propensity score methods with stabilized inverse probability of treatment weighting were applied to balance potential confounders between treatment groups. Results: In total, 19 909 NOAC users and 10 300 warfarin users were included. Patients receiving NOACs had significantly lower hazards of developing macrovascular complications (HR, 0.84 [95% CI, 0.78 to 0.91]; P < 0.001), microvascular complications (HR, 0.79 [CI, 0.73 to 0.85]; P < 0.001), glycemic emergency (HR, 0.91 [CI, 0.83 to 0.99]; P = 0.043), and mortality (HR, 0.78 [CI, 0.75 to 0.82]; P < 0.001) than those receiving warfarin. Analyses with propensity score matching showed similar results. Several sensitivity analyses further supported the robustness of our findings. Limitation: The claims-based data did not allow for detailed data on patients' lifestyles and laboratory examinations to be obtained. Conclusion: Non–vitamin K antagonist oral anticoagulants were associated with lower hazards of diabetes complications and mortality than warfarin in patients with AF and DM. Primary Funding Source: Hualien Tzu Chi Hospital.

Granulomatosis With Polyangiitis Presenting With Initially Isolated Cutaneous Facial Ulceration Without Early Other Characteristic Changes | Annals of Internal Medicine: Clinical Cases

Granulomatosis with polyangiitis (GPA) is a multiorgan system disease process in which cutaneous involvement is not uncommon. However, this article reports a case of GPA that presented with an unusually destructive chronic cutaneous facial lesion without other characteristic organ changes to suggest GPA, which represented a unique diagnostic challenge. It highlights the importance of maintaining high suspicion for vasculitic disease processes and prompt diagnosis to reduce disease burden.

Beyond Uremia: Chronic Kidney Disease as a Cryptic Gateway for Opportunistic Neuroinvasion by John Cunningham Virus | Annals of Internal Medicine: Clinical Cases

Progressive multifocal leukoencephalopathy (PML), a devastating demyelinating central nervous system infection caused by John Cunningham virus (JCV) reactivation, typically occurs in profound immunosuppression. Chronic kidney disease (CKD) induces a state of “immunoparalysis” through uremic toxin-mediated T-cell dysfunction yet remains an underrecognized risk factor for PML. We present a 72-year-old man with end-stage renal disease who developed subacute expressive aphasia and confusion. Magnetic resonance imaging showed demyelinating white matter lesions, and cerebrospinal fluid confirmed JCV DNA, establishing PML. This case highlights CKD as a cryptic immunosuppressive state predisposing to PML and emphasizes the importance of considering PML in patients with CKD presenting with new, progressive neurologic deficits.

Unveiling the Link: Exploring the Association Between Cancer and Leukocyte Chemotactic Factor 2 (ALECT2) Amyloidosis | Annals of Internal Medicine: Clinical Cases

We present a case of a 53-year-old Hispanic man with mantle cell lymphoma who developed progressive decline in estimated glomerular filtration rate despite no previous kidney disease or predisposing conditions. Findings of a renal biopsy revealed leukocyte chemotactic factor 2 (ALECT2) amyloidosis. Remarkably, after treatment of his lymphoma, the patient's estimated glomerular filtration rate normalized. Given the correlation between the patient's cancer and the improvement in kidney function after treatment, we hypothesize that his lymphoma may have acted as a trigger for ALECT2 amyloidosis through 1 or more potential mechanisms, including dysregulated Wnt/β-catenin signaling, tumor-related inflammatory pathways, or a second hit on an underlying genetic predisposition.

Successful Pregnancy in a Patient With Advanced Cystic Fibrosis Lung Disease and Burkholderia cenocepacia Colonization | Annals of Internal Medicine: Clinical Cases

Cystic fibrosis (CF) affects multiple aspects of health, including reproduction and fertility. This report details a case of a 38-year-old woman with several complications from her CF, including advanced CF lung disease, pancreatic exocrine insufficiency, asthma, and airway colonization with Burkholderia cenocepacia, who became pregnant and successfully delivered a baby boy without significant complications. This was an unplanned pregnancy 4 years after initiation of elexaftor/tezacaftor/ivacaftor therapy, a CF transmembrane conductance regulator modulator therapy that has significantly improved various health outcomes in patient populations with CF, including the reproductive health of women.

Atypical Skull Base Osteomyelitis From Streptococcus parasanguinis | Annals of Internal Medicine: Clinical Cases

Atypical skull base osteomyelitis is a rare condition that can lead to critical complications if left unrecognized. It is difficult to diagnose owing to nonspecific clinical presentations and delayed imaging findings. It typically occurs from nonotologic infections that affect the clivus and requires at least 6 weeks of antibiotics. This case describes a patient presenting with an acute left-sided headache who was eventually diagnosed with atypical skull base osteomyelitis caused by Streptococcus parasanguinis from a sinus infection.

Sigmoid Volvulus | Annals of Internal Medicine: Clinical Cases

An 83-year-old woman who resided in a nursing home presented to the emergency department with abdominal pain and vomiting resulting in the diagnosis of sigmoid volvulus. She needed intermittent catheter reduction of the colonic air but no surgical intervention has been performed so far.

Polymicrobial Bacteremia Due to SARS-CoV-2–Related Superior Mesenteric Vein Thrombosis | Annals of Internal Medicine: Clinical Cases

Superior mesenteric vein thrombosis (SMVT) is a rare but serious complication associated with COVID-19 infection that can lead to bowel ischemia or infarction. We discuss a case of SMVT presenting with septic shock due to polymicrobial bacteremia, including Bacteroides fragilis and Streptococcus anginosus, that preceded the identification of extensive thrombus involving the superior mesenteric vein. This case underscores the importance of considering SMVT as a differential diagnosis in patients post–COVID-19 presenting with polymicrobial bacteremia and highlights the need for prompt diagnosis and management to prevent further complications.

Alternating Transient Monocular Vision Loss Due to Giant Cell Arteritis | Annals of Internal Medicine: Clinical Cases

Giant cell arteritis is a systemic granulomatous vasculitis commonly involving the temporal artery and associated with visual deficits. The most common ocular presentation of giant cell arteritis involves anterior ischemic ocular neuropathy with sudden unilateral vision loss. We present a rare case of alternating painless monocular vision loss in an older man who responded clinically to prolonged glucocorticoid therapy, tocilizumab, and intraocular pressure–lowering ophthalmic medications.

Regional Myocarditis due to Legionella Masquerading as Dual-Chamber Cardiac Arrhythmia | Annals of Internal Medicine: Clinical Cases

Myocarditis, an inflammatory myocardial condition, often is associated with arrhythmias. Enhanced diagnostic capabilities have emerged from advanced imaging techniques such as fluorine-18–labeled deoxyglucose positron emission tomography and cardiac magnetic resonance imaging with late gadolinium enhancement. We present a rare case of Legionella myocarditis with concurrent dual-chamber arrhythmias while using multimodality imaging for diagnosis.

Systemic Emboli and Biventricular Hypertrophy Due to Glycogen Storage Disease: Clinical, Imaging, and Pathologic Predicament | Annals of Internal Medicine: Clinical Cases

Glycogen storage disease cardiomyopathy is being recognized increasingly as a mimicker of hypertrophic cardiomyopathy. It is important to diagnose these diseases, as there are prognostic and treatment ramifications. This case report discusses a patient who presented with cardioembolic renal infarction and was ultimately diagnosed with glycogen storage disease XV (which is extremely rare). The diagnosis was made by pursuing multimodality imaging, endomyocardial biopsy, and genetic testing.

A new understanding of UTIs | ACP Hospitalist

Malnutrition revisited | ACP Hospitalist

Updated warnings on fluoroquinolones, new diabetes drug approved | ACP Hospitalist

Sickle cell drug withdrawn from market | ACP Hospitalist

FDA provides info on stimulant shortage | ACP Hospitalist

A collection of individual cases | ACP Hospitalist

MKSAP quiz on oncology | ACP Hospitalist

Fighting the trust fall | ACP Hospitalist

Understanding charity care | ACP Hospitalist

Identify the toxin | ACP Hospitalist

Synopsis covers ADA update on pharmaceutical management of type 2 diabetes

Beyond the Guidelines: Should we screen for type 2 diabetes?

In the Clinic, Ideas and Opinions address diabetes

Review: Evidence is inconclusive on metabolic surgery vs. medical treatment for microvascular complications in T2DM

Spotlight on diabetes prevention programs

Differentiating type 1 from type 2 diabetes in adults

Annals On Call: Type 1 diabetes

Annals On Call: First-line drug therapy for type 2 diabetes

Targeting social needs may help improve type 2 diabetes outcomes, review finds

Few diabetes, hypertension patients get recommended testing for kidney disease