ACP Comment Letter Regarding the Notice of Benefit and Payment Parameters for 2024

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

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.

Clinical Characterization of Critically Ill Patients With Neurological Manifestation in Chikungunya Virus | Annals of Internal Medicine: Clinical Cases

This study presents 6 cases of severe meningoencephalitis associated with chikungunya virus infection in older adults with comorbid conditions who were admitted to an intensive care unit in Paraguay. The patients exhibited classic symptoms, such as fever and arthralgia, as well as sensory impairment. They required mechanical ventilation and vasoactive support. Reverse-transcription-polymerase chain reaction confirmed the infection in the cerebrospinal fluid, and the inflammatory and metabolic characteristics were suggestive of severe neurologic involvement. The 50% mortality rate highlights the severity of this complication in older patients. This emphasizes the need for a high index of suspicion for timely diagnosis and management.

Common Variable Immunodeficiency Presenting With Bilateral Optic Nerve Edema: Case Report | Annals of Internal Medicine: Clinical Cases

Common variable immunodeficiency is typically characterized by recurrent infections, autoimmunity, and primary antibody failure, with an increased risk for malignancy. Ophthalmic and neurologic complications are considered rare. We describe a unique case presenting with bilateral optic disc edema, which resolved with IgG replacement therapy.

A Surprising Complication: Arterial Thrombosis in a Patient Receiving RAD-140 (Testolone) | Annals of Internal Medicine: Clinical Cases

RAD-140 is a selective androgen receptor modulator (SARM) that has anabolic effects similar to those of some androgenic steroids and hormones such as testosterone. The androgenic activity of SARMs can increase the risk for thrombosis through various mechanisms. Here, we discuss the case of a 48-year-old man with a history of hypogonadism receiving testosterone replacement therapy taking RAD-140 as a supplement for bodybuilding who presented with arterial thrombosis. The patient was evaluated for hereditary thrombophilic conditions; his test results returned negative. Concurrent use of RAD-140 and testosterone may increase the risk for arterial thrombosis, highlighting the need for clinical awareness of supplement-related adverse effects.

Renal Subcapsular Hematoma: A Rare Potentially Reversible Cause of Acute Graft Dysfunction With Immediate Intervention | Annals of Internal Medicine: Clinical Cases

Subcapsular hematoma of the kidney allograft is an often underrecognized but reversible cause of acute graft dysfunction, which occurs most commonly after percutaneous biopsy. We retrospectively reviewed 4 cases diagnosed with subcapsular hematoma between 2020 and 2023. All patients developed acute kidney injury, hypertension, and graft pain following kidney biopsy. Only 1 recovered fully after prompt surgical evacuation; delayed presentation and intervention in the others resulted in permanent graft loss. These findings emphasize the need for high index of suspicion in post-biopsy patients with acute graft dysfunction, as early diagnosis and timely intervention are essential for preserving graft function.

Fulminant Vibrio vulnificus Infection Following Dog Scratch in a Transplant Recipient Who Is Immunosuppressed: A Case Report | Annals of Internal Medicine: Clinical Cases

A 58-year-old man who is immunosuppressed presented with severe left leg pain 1 day after sustaining a scratch from his dog, which had been swimming in warm coastal water. He quickly developed necrotizing bullae secondary to Vibrio vulnificus bacteremia, progressing to septic shock and multiorgan failure. Management included prompt surgical intervention, targeted antibiotics, and immunosuppressant de-escalation. Despite his grave prognosis, he recovered after 23 days. This case highlights an unconventional V vulnificus transmission route, underscoring the need for rapid diagnosis and treatment in high-risk patients with compatible symptoms, regardless of direct water exposure.

Infectious Aortitis Secondary to Gastrointestinal Pathogens: A Case Series and Syndromic Review | Annals of Internal Medicine: Clinical Cases

Aortitis is a rare but serious complication of infection that results in high morbidity and mortality. The most common location is in preexisting aneurysmal disease in a patient with multiple chronic comorbidities. The pathogens often reflect gastrointestinal bacteria, the classic example being Salmonella spp., but also include other enteric flora, Staphylococcus aureus, Streptococcus spp., and more. Herein, we describe 2 cases of aortitis caused by gastrointestinal bacteria and review management of this complex syndrome.

A Case of Renal Papillary Necrosis in Sickle Cell Trait: Distinct Erythrocyturia and Successful Treatment With Aminocaproic Acid | Annals of Internal Medicine: Clinical Cases

Renal papillary necrosis (RPN) is a rare condition characterized by gross hematuria; however, erythrocyte morphology under uroscopy is poorly described. The effectiveness of aminocaproic acid remains scarcely reported. We report a 50-year-old woman with persistent gross hematuria. Initial computed tomography (CT) and ultrasound results were inconclusive; a CT urogram confirmed the diagnosis. Hemoglobin electrophoresis was positive for hemoglobin S. Urinary sediment microscopy showed dysmorphic erythrocytes with pseudoacanthocyte appearance without ring-shaped morphology. Treatment with aminocaproic acid led to rapid resolution within 72 hours. This case highlights sickle cell trait as a cause of RPN, unique urinary erythrocyte morphology, CT urogram for diagnosis, and aminocaproic acid efficacy.

Tremors and Memory Loss From Hypomagnesemia and Hypocalcemia Secondary to Long-Term Proton Pump Inhibitor Use | Annals of Internal Medicine: Clinical Cases

Proton pump inhibitors (PPIs) are commonly prescribed for short-term use but are often taken chronically, including through over-the-counter (OTC) access. Long-term use has been linked to hypomagnesemia and hypocalcemia, which may cause serious complications. A 47-year-old man on PPIs for 5 years presented with cramps, spasms, tremors, disorientation, and amnesia. Tests showed low magnesium and calcium, with other causes excluded. Proton pump inhibitor treatment was discontinued and supplementation initiated, leading to marked recovery. Chronic PPI use should be considered in unexplained electrolyte abnormalities, even in patients not at high risk, highlighting the need for cautious prescribing, periodic monitoring, and reassessment of OTC availability.

Nocturnal Enuresis in an Adult With Obesity | Annals of Internal Medicine: Clinical Cases

We present a case of nocturnal enuresis (NE) in an adult with obesity that resolved with treatment of obstructive sleep apnea (OSA). The patient reported daytime somnolence and enuresis with no daytime urinary incontinence. A home sleep study diagnosed OSA. The patient received continuous positive airway pressure (CPAP) treatment with immediate resolution of enuresis. This case highlights the importance of recognizing enuresis as a potential symptom of sleep apnea.

Progressive Internal Carotid Artery Occlusion in IgG4-Related Disease: A Case Report and Literature Review | Annals of Internal Medicine: Clinical Cases

Immunoglobulin G4–related disease (IgG4-RD) is a systemic fibroinflammatory disorder capable of multiorgan involvement, though its association with cerebral vasculitis and large-vessel occlusion remains rare and poorly characterized. We report a novel case of cryptogenic ischemic stroke secondary to progressive internal carotid artery (ICA) stenosis and occlusion, ultimately attributed to IgG4-RD. The patient exhibited multifocal hypermetabolic lesions on positron emission tomography–computed tomography, correlating with arterial wall thickening and subsequent pathologic confirmation of IgG4-positive plasma cell infiltration. This case highlights IgG4-RD as an underrecognized cause of progressive ICA stenosis and occlusion, offering critical insights into the diagnostic work-up of cryptogenic stroke and expanding the spectrum of vascular manifestations in IgG4-RD.

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