ACP Statement for the Record to the House Ways and Means Committee on America"s Mental Health Crisis

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).

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.

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

Medicines for Treatment Intensification in Type 2 Diabetes and Type of Insulin in Type 1 and Type 2 Diabetes in Low-Resource Settings: Synopsis of the World Health Organization Guidelines on Second- and Third-Line Medicines and Type of Insulin for the Control of Blood Glucose Levels in Nonpregnant Adults With Diabetes Mellitus

Description: The World Health Organization developed these guidelines to provide guidance on selection of medicines for treatment intensification in type 2 diabetes and on use of insulin (human or analogue) in type 1 and 2 diabetes. The target audience includes clinicians, policymakers, national diabetes program managers, and medicine procurement officers. The target population is adults with type 1 or 2 diabetes in low-resource settings in low- or high-income countries. The guidelines also apply to disadvantaged populations in high-income countries. Methods: The recommendations were formulated by a 12-member guideline development group and are based on high-quality systematic reviews identified via a search of several bibliographic databases from 1 January 2007 to 1 March 2017. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of the evidence and the strength of the recommendations. The guideline was peer-reviewed by 6 external reviewers. Recommendation 1: Give a sulfonylurea to patients with type 2 diabetes who do not achieve glycemic control with metformin alone or who have contraindications to metformin (strong recommendation, moderate-quality evidence). Recommendation 2: Introduce human insulin treatment to patients with type 2 diabetes who do not achieve glycemic control with metformin and/or a sulfonylurea (strong recommendation, very-low-quality evidence). Recommendation 3: If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium–glucose cotransporter-2 (SGLT-2) inhibitor, or a thiazolidinedione (TZD) may be added (weak recommendation, very-low-quality evidence). Recommendation 4: Use human insulin to manage blood glucose in adults with type 1 diabetes and in adults with type 2 diabetes for whom insulin is indicated (strong recommendation, low-quality evidence). Recommendation 5: Consider long-acting insulin analogues to manage blood glucose in adults with type 1 or type 2 diabetes who have frequent severe hypoglycemia with human insulin (weak recommendation, moderate-quality evidence for severe hypoglycemia).

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 Rare Case of Doxycycline-Induced Autoimmune Hepatitis With Organizing Pneumonia | Annals of Internal Medicine: Clinical Cases

Autoimmune hepatitis and organizing pneumonia are uncommon, yet important, manifestations of drug toxicity. We describe the case of a 67-year-old woman who presented with shortness of breath shortly after completing a course of doxycycline and was incidentally found to have a prominent hepatitis. Subsequent evaluation yielded a diagnosis of doxycycline-induced autoimmune hepatitis and organizing pneumonia. This case gives credence to including drug-induced autoimmune hepatitis and organizing pneumonia in the differential for both liver injury and respiratory failure encountered in the setting of doxycycline exposure.

Lymphoid Interstitial Pneumonia Associated With Hashimoto Thyroid Disease | Annals of Internal Medicine: Clinical Cases

Lymphoid interstitial pneumonia (LIP) refers to the diffuse infiltration and accumulation of lymphocytes within the alveolar interstitium and may be associated with multiple autoimmune diseases, most notably Sjögren syndrome. Only rare cases of LIP have been reported in patients with Hashimoto thyroiditis. In these cases, the patients also had at least 1 additional autoimmune disease. We report a case of LIP in a 70-year-old woman whose only autoimmune disease was Hashimoto thyroiditis. This case supports the hypothesis that Hashimoto thyroiditis alone may instigate the development of LIP.

Severe Azithromycin-Induced Liver Injury With Vanishing Bile Duct Syndrome Necessitating Liver Transplantation | Annals of Internal Medicine: Clinical Cases

Drug-induced liver injury is a common cause of liver damage, with antimicrobial use as the leading cause. Although most patients recover after discontinuing the offending agent, severe cases may result in progressive disease or death, requiring liver transplantation. Azithromycin is a rare cause of idiosyncratic drug-induced liver injury, usually resolving within 4 to 8 weeks of discontinuation. Vanishing bile duct syndrome may occur in severe cases, marked by progressive ductopenia and cholestasis. We describe a rare case of azithromycin-induced liver injury with acute vanishing bile duct syndrome necessitating liver transplantation.

Right Coronary Artery Ectasia Manifesting With Acute Coronary Syndrome and Atrial Fibrillation: A Case Report | Annals of Internal Medicine: Clinical Cases

The patient is a 59-year-old man who presented with substernal chest pain. Electrocardiogram showed evidence of inferior ST-segment elevation, and his troponin I level peaked at 40 µg/L. Coronary angiogram showed a severely ectatic right coronary artery with near-total acute thrombotic occlusion of the distal right coronary artery and total acute thrombotic occlusion of the distal posterior descending artery. He had a successful intravascular ultrasound-guided aspiration thrombectomy with a penumbra and intracoronary tissue plasminogen activator infusion. This case highlights an alternative way of treating acute thrombotic occlusion of ectatic arteries asides from the conventional but challenging practice of coronary revascularization with stent placement.

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