ACP's Written Testimony for the Senate Judiciary Subcommittee on Antitrust, Competition Policy, and Consumer Rights Hearing on the CREATES ACT: Ending Regulatory Abuse, Protecting Consumers, and Ensuring Drug Price Competition

Joint Principles on Rising Costs and Growing Shortages of Prescription Drugs

The Urban Health Penalty: New Dimensions and Directions in Inner-City Health Care.

Revitalization of Internal Medicine: Overview of the Problems and Recommendations on Reducing Medical Student Debt

HIV Policy: The Path Forward

The Crisis in Correctional Health Care: The Impact of the National Drug Control Strategy on Correctional Health Services

Assessing Individual Physician Performance by Managed Care Organizations

Letter to the Department of Veterans Administration regarding the Advanced Practice Registered Nurses Proposed Rule

Medicare Physician Fee Schedule for Calendar Year 2002. Letter to the Centers for Medicare & Medicaid Services (CMS).

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

Diabetes Technology: Review of the 2019 American Diabetes Association Standards of Medical Care in Diabetes

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: The ADA Professional Practice Committee comprises physicians, adult and pediatric endocrinologists, diabetes educators, registered dietitians, epidemiologists, pharmacists, and public health experts. To develop the 2019 standards, the committee continuously searched MEDLINE through November 2018 to consider and review studies, particularly high-quality trials including persons with diabetes, for potential incorporation into recommendations. It also solicited feedback from the larger clinical community. Recommendations: This synopsis focuses on selected guidance relating to use of diabetes technology in adults with diabetes. Recommendations address self-monitoring of blood glucose, continuous glucose monitors, and automated insulin delivery systems.

To What Target Hemoglobin A1c Level Would You Treat This Patient With Type 2 Diabetes?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 171, No 7

In the United States, 9.4% of all adults—and 25% of those older than 65 years—have diabetes. Diabetes is the leading cause of blindness and end-stage renal disease and contributes to both microvascular and macrovascular complications. The management of patients with type 2 diabetes (T2D) is a common and important activity in primary care internal medicine practice. Measurement of hemoglobin A1c (HbA1c) provides an estimate of mean blood sugar levels and glycemic control. The optimal HbA1c target level among various persons with T2D is a subject of controversy. Guidelines regarding HbA1c targets have yielded differing recommendations. In 2018, the American College of Physicians (ACP) published a guideline on HbA1c targets for nonpregnant adults with T2D. In addition to a recommendation to individualize HbA1c target levels, the ACP proposed a level between 7% and 8% for most patients. The ACP also advised deintensification of therapy for patients who have an HbA1c level lower than 6.5% and avoidance of HbA1c-targeted treatment for patients with a life expectancy of less than 10 years. This guidance contrasts with a recommendation from the American Diabetes Association to aim for HbA1c levels less than 7% for many nonpregnant adults and to consider a target of 6.5% if it can be achieved safely. Here, 2 experts, a diabetologist and a general internist, discuss how to apply the divergent guideline recommendations to a patient with long-standing T2D and a current HbA1c level of 7.8%.

Maternal Glycemic Control in Type 1 Diabetes and the Risk for Preterm Birth: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 170, No 10

Background: Maternal type 1 diabetes (T1D) has been linked to preterm birth and other adverse pregnancy outcomes. How these risks vary with glycated hemoglobin (or hemoglobin A1c [HbA1c]) levels is unclear. Objective: To examine preterm birth risk according to periconceptional HbA1c levels in women with T1D. Design: Population-based cohort study. Setting: Sweden, 2003 to 2014. Patients: 2474 singletons born to women with T1D and 1 165 216 reference infants born to women without diabetes. Measurements: Risk for preterm birth (<37 gestational weeks). Secondary outcomes were neonatal death, large for gestational age, macrosomia, infant birth injury, hypoglycemia, respiratory distress, 5-minute Apgar score less than 7, and stillbirth. Results: Preterm birth occurred in 552 (22.3%) of 2474 infants born to mothers with T1D versus 54 287 (4.7%) in 1 165 216 infants born to mothers without diabetes. The incidence of preterm birth was 13.2% in women with a periconceptional HbA1c level below 6.5% (adjusted risk ratio [aRR] vs. women without T1D, 2.83 [95% CI, 2.28 to 3.52]), 20.6% in those with a level from 6.5% to less than 7.8% (aRR, 4.22 [CI, 3.74 to 4.75]), 28.3% in those with a level from 7.8% to less than 9.1% (aRR, 5.56 [CI, 4.84 to 6.38]), and 37.5% in those with a level of 9.1% or higher (aRR, 6.91 [CI, 5.85 to 8.17]). The corresponding aRRs for medically indicated preterm birth (n = 320) were 5.26 (CI, 3.83 to 7.22), 7.42 (CI, 6.21 to 8.86), 11.75 (CI, 9.72 to 14.20), and 17.51 (CI, 14.14 to 21.69), respectively. The corresponding aRRs for spontaneous preterm birth (n = 223) were 1.81 (CI, 1.31 to 2.52), 2.86 (CI, 2.38 to 3.44), 2.88 (CI, 2.23 to 3.71), and 2.80 (CI, 1.94 to 4.03), respectively. Increasing HbA1c levels were associated with the study's secondary outcomes: large for gestational age, hypoglycemia, respiratory distress, low Apgar score, neonatal death, and stillbirth. Limitation: Because HbA1c levels were registered annually at routine visits, they were not available for all pregnant women with T1D. Conclusion: The risk for preterm birth was strongly linked to periconceptional HbA1c levels. Women with HbA1c levels consistent with recommended target levels also were at increased risk. Primary Funding Source: Swedish Diabetes Foundation.

Excess Burden of Mental Illness and Hospitalization in Young-Onset Type 2 Diabetes: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 170, No 3

Background: Type 2 diabetes (T2D) increases hospitalization risk. Young-onset T2D (YOD) (defined as onset before age 40 years) is associated with excess morbidity and mortality, but its effect on hospitalizations is unknown. Objective: To determine hospitalization rates among persons with YOD and to examine the effect of age at onset on hospitalization risk. Design: Prospective cohort study. Setting: Hong Kong. Participants: Adults aged 20 to 75 years in population-based (2002 to 2014; n = 422 908) and registry-based (2000 to 2014; n = 20 886) T2D cohorts. Measurements: All-cause and cause-specific hospitalization rates. Negative binomial regression models estimated effect of age at onset on hospitalization rate and cumulative bed-days from onset to age 75 years for YOD. Results: Patients with YOD had the highest hospitalization rates by attained age. In the registry cohort, 36.8% of YOD bed-days before age 40 years were due to mental illness. The adjusted rate ratios showed increased hospitalization in YOD versus usual-onset T2D (onset at age ≥40 years) (all-cause, 1.8 [95% CI, 1.7 to 2.0]; renal, 6.7 [CI, 4.2 to 10.6]; diabetes, 3.7 [CI, 3.0 to 4.6]; cardiovascular, 2.1 [CI, 1.8 to 2.5]; infection, 1.7 [CI, 1.4 to 2.1]; P < 0.001 for all). Models estimated that intensified risk factor control in YOD (hemoglobin A1c level <6.2%, systolic blood pressure <120 mm Hg, low-density lipoprotein cholesterol level <2.0 mmol/L [<77.3 mg/dL], triglyceride level <1.3 mmol/L [<115.1 mg/dL], waist circumference of 85 cm [men] or 80 cm [women], and smoking cessation) was associated with a one-third reduction in cumulative bed-days from onset to age 75 years (97 to 65 bed-days). Limitation: Possible residual confounding. Conclusion: Adults with YOD have excess hospitalizations across their lifespan compared with persons with usual-onset T2D, including an unexpectedly large burden of mental illness in young adulthood. Efforts to prevent YOD and intensify cardiometabolic risk factor control while focusing on mental health are urgently needed. Primary Funding Source: Asia Diabetes Foundation.

Long-Term Weight Loss With Metformin or Lifestyle Intervention in the Diabetes Prevention Program Outcomes Study

Background: Identifying reliable predictors of long-term weight loss (LTWL) could lead to improved weight management. Objective: To identify some predictors of LTWL. Design: The DPP (Diabetes Prevention Program) was a randomized controlled trial that compared weight loss with metformin, intensive lifestyle intervention (ILS), or placebo. Its Outcomes Study (DPPOS) observed patients after the masked treatment phase ended. (ClinicalTrials.gov: NCT00004992 and NCT00038727) Setting: 27 DPP and DPPOS clinics. Participants: Of the 3234 randomly assigned participants, 1066 lost at least 5% of baseline weight in the first year and were followed for 15 years. Measurements: Treatment assignment, personal characteristics, and weight. Results: After 1 year, 289 (28.5%) participants in the metformin group, 640 (62.6%) in the ILS group, and 137 (13.4%) in the placebo group had lost at least 5% of their weight. After the masked treatment phase ended, the mean weight loss relative to baseline that was maintained between years 6 and 15 was 6.2% (95% CI, 5.2% to 7.2%) in the metformin group, 3.7% (CI, 3.1% to 4.4%) in the ILS group, and 2.8% (CI, 1.3% to 4.4%) in the placebo group. Independent predictors of LTWL included greater weight loss in the first year in all groups, older age and continued metformin use in the metformin group, older age and absence of either diabetes or a family history of diabetes in the ILS group, and higher fasting plasma glucose levels at baseline in the placebo group. Limitation: Post hoc analysis; examination of nonrandomized subsets of randomized groups after year 1. Conclusion: Among persons with weight loss of at least 5% after 1 year, those originally randomly assigned to metformin had the greatest loss during years 6 to 15. Older age and the amount of weight initially lost were the most consistent predictors of LTWL maintenance. Primary Funding Source: National Institutes of Health.

Brief Commentary: Laboratory Accuracy of Hemoglobin A1c Ranges and Treatment Targets for Patients With Type 2 Diabetes

Two in One: Diagnosing Type 2 Diabetes With Single-Sample Testing

Brief Commentary: Confusing Treatment Guidelines for Patients With Type 2 Diabetes

Brief Commentary: Social Determinants of Health and Treatment Targets for Type 2 Diabetes

Brief Commentary: Glycemic Targets for Older Adults With Type 2 Diabetes

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.

A Case of Gas-Containing Brain Abscess, From Superficial to Deep | Annals of Internal Medicine: Clinical Cases

Gas-containing brain abscess is a rare clinical emergency. Brain abscess with a distant history of mastoid surgery is uncommon. Management of this rare condition involves clinical vigilance, prompt diagnosis, surgical drainage, and antibiotics treatment. We report a case of a 45-year-old Filipino woman with tympanomastoidectomy 2 months prior who presented with headache and right retroauricular wound with discharge. Prompt diagnosis and surgical drainage resulted in excellent neurologic outcome. The knowledge of characteristics of pathogens is vital in pharmacologic management.

Low-Molecular-Weight Heparin–Induced Skin Necrosis Without Thrombocytopenia | Annals of Internal Medicine: Clinical Cases

Heparin-induced skin necrosis is an immune-based entity that appears secondary to exposure to unfractionated heparin or low-molecular-weight heparin, consisting of the appearance of erythematous lesions that can progress to necrosis at the point of heparin inoculation or in remote places. A case of a patient with the appearance of necrotic erythematous lesions in the lower limbs 10 days after the introduction of enoxaparin at an anticoagulant dose is presented.

Unilateral Diaphragm Paralysis Following COVID-19 Infection: A Case Report | Annals of Internal Medicine: Clinical Cases

We report a patient case of unilateral diaphragm paralysis following COVID-19 infection. A 55-year-old healthy man was infected with SARS-CoV-2 before the availability of a vaccine. He was intubated and pronated for respiratory failure. He experienced new debilitating dyspnea and orthopnea for 6 months after recovery. Dynamic chest radiography demonstrated a new hemidiaphragm paralysis. After surgical plication of the diaphragm, the patient's symptoms resolved. This patient case demonstrates the importance of thorough evaluation for diaphragm paralysis in patients who have suffered COVID-19 infection when there is persistent dyspnea or orthopnea, as well as the neuroinvasive potential of the virus that has yet to be fully explained.

Lisinopril-Induced Burning Mouth Syndrome | Annals of Internal Medicine: Clinical Cases

Burning mouth syndrome (BMS) is defined as an uncomfortable burning sensation in the mouth and/or tongue in the absence of any oral mucosa lesions, sores, or other abnormalities. We describe a case in which a patient had a burning sensation in her mouth for several years with no identifiable cause. Two weeks after her primary care physician switched her lisinopril to another antihypertensive medication, she noted significant improvement in her symptoms and an improved quality of life. It is imperative for physicians to recognize angiotensin-converting enzyme inhibitors, specifically lisinopril, as a possible cause of burning mouth syndrome in symptomatic patients.

A Young Patient With Lupus Nephritis and Cryptococcemia Lacking Central Nervous System Involvement | Annals of Internal Medicine: Clinical Cases

There has been a recent increase in the prevalence of cryptococcal infections worldwide due to increased prevalence of immunosuppressed individuals secondary to AIDS, autoimmune disease, or neoplastic disease. Cryptococcus neoformans infection typically presents as a meningoencephalitis; however, there is low incidence of cryptococcemia in the absence of central nervous system and other organ involvement. Here we present a case of a 26-year-old female patient with lupus nephritis on immunosuppressants found to have asymptomatic cryptococcemia in the absence of meningoencephalitis and other organ involvement.

Renovascular Hypertension: Unraveling a Case of Mixed Histiocytosis | Annals of Internal Medicine: Clinical Cases

Renovascular hypertension is a cause of secondary hypertension. Atherosclerotic renal artery stenosis and fibromuscular dysplasia are the main causes, but other rare entities can involve the renal arteries. Erdheim-Chester disease is a non-Langerhans cell histiocytosis with a heterogenous clinical presentation and prognosis. We report a case of a 63-year-old woman with a history of Langerhans cell histiocytosis presenting with difficult-to-treat hypertension. A literature review is presented, and owing to the pathophysiology and anatomical characteristics of the vascular attainment, we propose that angioplasty with stenting, as preconized for atherosclerotic renal artery stenosis, should be the preferred treatment approach.

ADA conference coverage on kidneys, weight, and insulin switches

HbA1c targets debated, history of SGLT-2 inhibitors explained

Expert panel recommends target ranges for continuous glucose monitoring data

MKSAP quiz: Second-line therapy

Sickle cell trait affects HbA1c's accuracy as a measure of glycemia, study finds

Diabetic ketoacidosis in a prediabetic patient on ophthalmic steroids

Hospitalists dip into DKA

Treating skin ulcers in the office