ACP Letter of Support for H.R. 7120, the George Floyd Justice in Policing Act

ACP letter to the Occupational Safety and Health Administration regarding workplace violence in the health care sector and protection of vaccine providers

Joint Letter to Senate Opposing Proposed Changes to Medicaid

Joint Letter to DHS on Vaccinating Detainees in the Custody of U.S. Customs and Border Protection Against Influenza

ACP Response to the Ways and Means and Energy and Commerce Committees on Bipartisan Medicare Part D Drug Pricing Legislation

ACP Response to Senate Finance Committee Inquiry Concerning Policies to Improve Behavioral Health Care

ACP Letter to NTIA Regarding Privacy, Equity, and Civil Rights: Request for Comment

Letter to the House Committee on Oversight and Reform: Hearing on Examining the Actions of Drug Companies in Raising Prescription Drug Prices

ACP Letter to House Leaders Regarding Dobbs vs Jackson Women’s Health Organization Supreme Court Decision

ACP Letter to FDA Urging Review of Blood Donation Policy for Gay and Bisexual Men

World Health Organization Guidelines on Medicines for Diabetes Treatment Intensification: Commentary From the American College of Physicians High Value Care Committee

Comparative Benefits and Harms of Basal Insulin Analogues for Type 2 Diabetes: A Systematic Review and Network Meta-analysis: Annals of Internal Medicine: Vol 169, No 3

Background: Basal insulin analogues aim for protracted glycemic control with minimal adverse effects. Purpose: To assess the comparative efficacy and safety of basal insulin analogues for adults with type 2 diabetes mellitus (T2DM). Data Sources: Several databases from inception to April 2018 without language restrictions, ClinicalTrials.gov to April 2018, references of reviews, and meeting abstract books. Study Selection: Randomized trials lasting at least 12 weeks that compared efficacy (change in hemoglobin A1c [HbA1c] level from baseline [primary outcome]; percentage of patients with HbA1c level <7% at end of study and change in body weight [secondary outcomes]) and safety (hypoglycemia) of basal insulin analogues. Data Extraction: Two authors independently extracted data and assessed risk of bias for each outcome. All authors evaluated overall confidence in the evidence. Data Synthesis: Thirty-nine trials (26 195 patients) assessed 10 basal insulin analogues. Low- to very-low-quality evidence indicated that thrice-weekly degludec (Deg-3TW) was inferior to most other regimens for reducing HbA1c level, with mean differences ranging from 0.21% (vs. degludec, 100 U/mL [Deg-100]) to 0.32% (vs. glargine, 300 U/mL [Glar-300]). High- to moderate-quality evidence suggested that detemir had a favorable weight profile versus all comparators, and Glar-300 was associated with less weight gain than glargine, 100 U/mL (Glar-100); Deg-100; degludec, 200 U/mL (Deg-200); Deg-3TW; and LY2963016. Low- and very-low-quality evidence suggested that Deg-100, Deg-200, and Glar-300 were associated with lower incidence of nocturnal hypoglycemia than detemir, Glar-100, LY2963016, and neutral protamine lispro (NPL). Incidence of severe hypoglycemia did not differ among regimens, except NPL, which was associated with increased risk versus Deg-100, detemir, Glar-100, and Glar-300. Limitations: Results are based mostly on indirect comparisons. Confidence in summary estimates is low or very low due to individual-study limitations, imprecision, or inconsistency. Conclusion: Low-quality evidence suggests that basal insulin analogues for T2DM do not substantially differ in their glucose-lowering effect. Low- and very-low-quality evidence suggests some regimens may be associated with lower risk for nocturnal hypoglycemia (Deg-100, Deg-200, and Glar-300) or less weight gain (detemir and Glar-300). Primary Funding Source: None. (PROSPERO: CRD42016037055)

Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018

Description: The American Diabetes Association (ADA) annually updates its Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. Methods: For the 2018 standards, the ADA Professional Practice Committee searched MEDLINE through November 2017 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C depending on the quality of evidence or E for expert consensus or clinical experience. The standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. Recommendations: This synopsis focuses on guidance relating to cardiovascular disease and risk management in nonpregnant adults with diabetes. Recommendations address diagnosis and treatment of cardiovascular risk factors (hypertension and dyslipidemia), aspirin use, screening for and treatment of coronary heart disease, and lifestyle interventions.

Prognostic Implications of Single-Sample Confirmatory Testing for Undiagnosed Diabetes: A Prospective Cohort Study: Annals of Internal Medicine: Vol 169, No 3

Background: Current clinical definitions of diabetes require repeated blood work to confirm elevated levels of glucose or hemoglobin A1c (HbA1c) to reduce the possibility of a false-positive diagnosis. Whether 2 different tests from a single blood sample provide adequate confirmation is uncertain. Objective: To examine the prognostic performance of a single-sample confirmatory definition of undiagnosed diabetes. Design: Prospective cohort study. Setting: The ARIC (Atherosclerosis Risk in Communities) study. Participants: 13 346 ARIC participants (12 268 without diagnosed diabetes) with 25 years of follow-up for incident diabetes, cardiovascular outcomes, kidney disease, and mortality. Measurements: Confirmed undiagnosed diabetes was defined as elevated levels of fasting glucose (≥7.0 mmol/L [≥126 mg/dL]) and HbA1c (≥6.5%) from a single blood sample. Results: Among 12 268 participants without diagnosed diabetes, 978 had elevated levels of fasting glucose or HbA1c at baseline (1990 to 1992). Among these, 39% had both (confirmed undiagnosed diabetes), whereas 61% had only 1 elevated measure (unconfirmed undiagnosed diabetes). The confirmatory definition had moderate sensitivity (54.9%) but high specificity (98.1%) for identification of diabetes cases diagnosed during the first 5 years of follow-up, with specificity increasing to 99.6% by 15 years. The 15-year positive predictive value was 88.7% compared with 71.1% for unconfirmed cases. Confirmed undiagnosed diabetes was significantly associated with cardiovascular and kidney disease and mortality, with stronger associations than unconfirmed diabetes. Limitation: Lack of repeated measurements of fasting glucose and HbA1c. Conclusion: A single-sample confirmatory definition of diabetes had a high positive predictive value for subsequent diagnosis and was strongly associated with clinical end points. Our results support the clinical utility of using a combination of elevated fasting glucose and HbA1c levels from a single blood sample to identify undiagnosed diabetes in the population. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases and National Heart, Lung, and Blood Institute.

High-Deductible Insurance and Delay in Care for the Macrovascular Complications of Diabetes

Background: Little is known about the long-term effects of high-deductible insurance on care for chronic medical conditions. Objective: To determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes. Design: Observational longitudinal comparison of matched groups. Setting: A large national health insurer during 2003 to 2012. Participants: The intervention group comprised 33 957 persons with diabetes who were continuously enrolled in low-deductible (≤$500) insurance plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans. The control group included 294 942 persons with diabetes who were enrolled in low-deductible plans contemporaneously with matched intervention group members. Intervention: Employer-mandated transition to a high-deductible plan. Measurements: The number of months it took for persons in each study group to seek care for their first major macrovascular symptom, have their first major diagnostic test for macrovascular disease, and have their first major procedure-based treatment was determined. Between-group differences in time to reach a midpoint event rate were then calculated. Results: No baseline differences were found between groups. During follow-up, the delay for the high-deductible group was 1.5 months (95% CI, 0.8 to 2.3 months) for seeking care for the first major symptom, 1.9 months (CI, 1.4 to 2.3 months) for the first diagnostic test, and 3.1 months (CI, 0.5 to 5.8 months) for the first procedure-based treatment. Limitation: Health outcomes were not examined. Conclusion: Among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test, and the first procedure-based treatment. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.

Rethinking Rates of Undiagnosed Diabetes: The Value of a Confirmatory Test

Continuous Glucose Monitoring in Patients With Type 2 Diabetes Receiving Insulin Injections: Does This Mean Continuous Glucose Monitoring for Everyone?

Intermediate Diabetes Outcomes in Patients Managed by Physicians, Nurse Practitioners, or Physician Assistants: A Cohort Study: Annals of Internal Medicine: Vol 169, No 12

Background: Primary care provided by nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a solution to expected workforce shortages. Objective: To examine potential differences in intermediate diabetes outcomes among patients of physician, NP, and PA primary care providers (PCPs). Design: Cohort study using data from the U.S. Department of Veterans Affairs (VA) electronic health record. Setting: 568 VA primary care facilities. Patients: 368 481 adult patients with diabetes treated pharmaceutically. Measurements: The relationship between the profession of the PCP (the provider the patient visited most often in 2012) and both continuous and dichotomous control of hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) was examined on the basis of the mean of measurements in 2013. Inverse probability of PCP type was used to balance cohort characteristics. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes, respectively. Results: The PCPs were physicians (n = 3487), NPs (n = 1445), and PAs (n = 443) for 74.9%, 18.2%, and 6.9% of patients, respectively. The difference in HbA1c values compared with physicians was −0.05% (95% CI, −0.07% to −0.02%) for NPs and 0.01% (CI, −0.02% to 0.04%) for PAs. For SBP, the difference was −0.08 mm Hg (CI, −0.34 to 0.18 mm Hg) for NPs and 0.02 mm Hg (CI, −0.42 to 0.38 mm Hg) for PAs. For LDL-C, the difference was 0.01 mmol/L (CI, 0.00 to 0.03 mmol/L) (0.57 mg/dL [CI, 0.03 to 1.11 mg/dL]) for NPs and 0.03 mmol/L (CI, 0.01 to 0.05 mmol/L) (1.08 mg/dL [CI, 0.25 to 1.91 mg/dL]) for PAs. None of these differences were clinically significant. Limitation: Most VA patients are men who receive treatment in a staff-model health care system. Conclusion: No clinically significant variation was found among the 3 PCP types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs. Primary Funding Source: VA Health Services Research and Development.

Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus

Description: In April 2017, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management of type 2 diabetes mellitus. Methods: The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through June 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Recommendations: This synopsis summarizes key features of the guideline in 7 areas: patient-centered care and shared decision making, glycemic biomarkers, hemoglobin A1c target ranges, individualized treatment plans, outpatient pharmacologic treatment, glucose targets for critically ill patients, and treatment of hospitalized patients.

Identifying Trends in Undiagnosed Diabetes in U.S. Adults by Using a Confirmatory Definition: A Cross-sectional Study: Annals of Internal Medicine: Vol 167, No 11

Background: A common belief is that one quarter to one third of all diabetes cases remain undiagnosed. However, such prevalence estimates may be overstated by epidemiologic studies that do not use confirmatory testing, as recommended by clinical diagnostic criteria. Objective: To provide national estimates of undiagnosed diabetes by using a confirmatory testing strategy, in line with clinical practice guidelines. Design: Cross-sectional study. Setting: National Health and Nutrition Examination Survey results from 1988 to 1994 and 1999 to 2014. Participants: U.S. adults aged 20 years and older. Measurements: Confirmed undiagnosed diabetes was defined as elevated levels of fasting glucose (≥7.0 mmol/L [≥126 mg/dL]) and hemoglobin A1c (≥6.5%) in persons without diagnosed diabetes. Results: The prevalence of total (diagnosed plus confirmed undiagnosed) diabetes increased from 5.5% (9.7 million adults) in 1988 to 1994 to 10.8% (25.5 million adults) in 2011 to 2014. Confirmed undiagnosed diabetes increased during the past 2 decades (from 0.89% in 1988 to 1994 to 1.2% in 2011 to 2014) but has decreased over time as a proportion of total diabetes cases. In 1988 to 1994, the percentage of total diabetes cases that were undiagnosed was 16.3%; by 2011 to 2014, this estimate had decreased to 10.9%. Undiagnosed diabetes was more common in overweight or obese adults, older adults, racial/ethnic minorities (including Asian Americans), and persons lacking health insurance or access to health care. Limitation: Cross-sectional design. Conclusion: Establishing the burden of undiagnosed diabetes is critical to monitoring public health efforts related to screening and diagnosis. When a confirmatory definition is used, undiagnosed diabetes is a relatively small fraction of the total diabetes population; most U.S. adults with diabetes (about 90%) have received a diagnosis of the condition. Primary Funding Source: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases and National Heart, Lung, and Blood Institute.

Thromboangiitis Obliterans Successfully Treated With Smoking-Cessation Instruction Including Passive Smoking Cessation | Annals of Internal Medicine: Clinical Cases

A 22-year-old man presented with recurrent pain and linear redness of the lower extremities for 1 year. He smoked 20 cigarettes daily for 6 years and did not report cannabis use. He was referred to the vascular department by his primary care physician. He had stopped smoking for 6 months to treat thromboangiitis obliterans, but his symptoms were recurrent. The patient was interviewed about smoking in his living environment. His family members and his colleagues were smokers. Therefore, we advised to avoid secondhand smoke as well. Consequently, his symptoms resolved within 2 weeks. He had no relapse at follow-up after 6 months.

Recurrent Myopericarditis and Fulminant Cardiogenic Shock Due to Autoimmune Polyglandular Syndrome 2 | Annals of Internal Medicine: Clinical Cases

A 34-year-old man presented with acute pericarditis and a small pericardial effusion but rapidly decompensated into cardiac tamponade and fulminant cardiogenic shock, requiring venoarterial extracorporeal membrane oxygenation cannulation. He was diagnosed with autoimmune polyglandular syndrome 2 and was treated with stress dose steroids and an interleukin-1 inhibitor, with improvement in his cardiac function.

Infectious Proctitis From Cytomegalovirus in an Immunocompetent Patient | Annals of Internal Medicine: Clinical Cases

Cytomegalovirus colitis typically causes immunocompromised patients to present with hematochezia, abdominal pain, fever, or diarrhea and rarely as perforation. Here we report an 83-year-old woman with no other traditional immunocompromising risk factors who presented with cytomegalovirus proctitis. Providers should be aware of the potential for this severity of presentation even in immunocompetent patients.

Thymic Hyperplasia in Graves’ Disease: A Case Report | Annals of Internal Medicine: Clinical Cases

Thymic hyperplasia can occur secondary to Graves’ disease, although the exact mechanism is not yet entirely understood. Thymic hyperplasia in this setting is typically benign and improves with treatment of Graves’ disease. Invasive procedures are generally not required but should be considered if suspicion for other underlying disease processes (including malignancy) is suspected and/or imaging does not show thymus regression after antithyroid therapy.

Immune-Mediated Necrotizing Myopathy Associated With Myelodysplastic Syndrome | Annals of Internal Medicine: Clinical Cases

Autoimmune diseases can often be diagnosed in patients with myelodysplastic syndrome (MDS). Here, we review the emerging literature linking MDS and rare presentations of autoimmunity, including myositis. We report a patient case that underscores the consideration of myositis as an autoimmune manifestation of MDS: initial presentation included shoulder pain and fevers, and after concurrent diagnoses of MDS and autoimmune myositis, the patient continued to present periodically with recurrent flares despite immunosuppressive treatment. Timely diagnosis of MDS-associated myositis may be challenging due to concurrent fever and hemolytic anemia. Furthermore, accurate diagnosis must exclude statin-induced myopathy, effect of toxins, or infectious etiologies.

Systemic Lupus Erythematosus: Initial Manifestation as Cardiac Tamponade? | Annals of Internal Medicine: Clinical Cases

A 49-year-old man presented with 1 hour of retrosternal chest pain and ST-segment elevation. In the ambulance, he was diagnosed with an ST-segment elevation myocardial infarction and received prompt fibrinolysis. On arrival to the percutaneous coronary intervention–capable hospital, he became hemodynamically unstable, and bedside echocardiogram demonstrated a posterior pericardial effusion with tamponade physiology. He was found be profoundly thrombocytopenic secondary to a history of immune thrombocytopenic purpura (not known at the time of prehospital fibrinolysis). Given the position of his pericardial effusion, emergent surgical drainage was performed without complication. Subsequent work-up confirmed effusive pericarditis as his presenting diagnosis secondary to systemic lupus erythematosus.

Insights Into a Hypercoagulable Case of Thyrocardiac Disease and Literature Overview | Annals of Internal Medicine: Clinical Cases

Hyperthyroidism is associated with a hypercoagulable state and has been described previously in case studies in the context of cerebral vein thrombosis and pulmonary emboli. In this case report, we present a middle-aged man with a rare combination of rheumatic mitral valve disease and thyroid storm complicated by enormous intracardiac thrombus burden. We aim to highlight the hypercoagulable state associated with thyrocardiac disease and to alert the physician to remain vigilant for not only this clinical entity but also for multiple disease states occurring in 1 patient.

Pituitary Apoplexy as a Mimicker of Infectious Meningitis in an Adolescent Female Patient | Annals of Internal Medicine: Clinical Cases

Pituitary apoplexy can cause a chemical meningitis, and its mimicry in presentation with infectious meningitis poses a diagnostic challenge. Here we report an 18-year-old woman who presented with acute headache, altered mental status, and cerebral spinal fluid (CSF) pleocytosis and clinically improved with antibiotics and steroids. Despite an unremarkable computed tomography (CT) scan of the head, brain magnetic resonance imaging showed a pituitary macroadenoma with apoplexy. To our knowledge, this is one of the first reports of an adolescent with pituitary apoplexy masquerading as infectious meningitis and underscores the importance of keeping this rare condition, often missed on CT scans, as part of the differential for CSF pleocytosis.

Near-Simultaneous Development of Coronary and Pulmonary Thrombosis in a Patient With COVID-19 | Annals of Internal Medicine: Clinical Cases

Venous thromboembolism and in situ thrombosis are recognized complications of SARS-CoV-2 infection and are associated with adverse outcomes. The development of multiple thrombotic events in patients with COVID-19 has been reported, although the combination of venous and arterial thrombotic events is rarely recognized. Here, we describe a 42-year-old man without significant risk factors for cardiovascular disease who developed a segmental pulmonary thrombus and coronary thrombus within hours while hospitalized for the treatment of nonsevere COVID-19 pneumonia.

Therapeutic Low-Density Lipoprotein Cholesterol-Lowering in a Patient With Familial Hyperlipidemia Refractory to PCSK9 Monoclonal Antibody (Evolocumab) | Annals of Internal Medicine: Clinical Cases

Patients with heterozygous familial hypercholesterolemia if untreated are at increased risk for atherosclerotic cardiovascular disease events by age 40 years. Inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9) is a demonstrated potent approach to low-density lipoprotein cholesterol (LDL-C)-lowering in this population. We describe a 67-year-old patient with heterozygous familial hypercholesterolemia who developed a paradoxical increase in LDL-C while on a PCSK9 monoclonal antibody but had a subsequent reduction in LDL-C when started on inclisiran, a PCSK9-directed oligonucleotide. The overall mechanism of monoclonal antibody refractoriness remains to be determined, but it indicates that PCSK9 as a target is still a viable option using a different mechanism.