Search Results for: "diabetes_articles"

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).

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.

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Displaying 61 - 70 of 142 in Annals of Internal Medicine: Clinical Cases

Recurrent Plaque Erosion in a Young Patient | Annals of Internal Medicine: Clinical Cases

Plaque erosion is one of the important mechanisms of acute coronary syndromes. We report the first case of recurrent plaque erosion in a different vessel 9 years after the initial episode.

A Peculiar Manifestation of Chronic Myelogenous Leukemia in Lymphoid Blast Crisis | Annals of Internal Medicine: Clinical Cases

A 61-year-old man with a history of factor V Leiden mutation, hypothyroidism, and transient ischemic attacks presented to his physician's office but could not recall the reason for his visit. Initial laboratory test results showed a slight leukocytosis with slight basophilia; neuro-immunologic, infectious, and metabolic work-up was unrevealing. Flow cytometry results showed atypical B lymphoblasts. Bone marrow biopsy results revealed a hypercellular bone marrow with CD10 staining lymphoblasts and Philadelphia chromosomal translocation. Hematologic malignancy fusion panel results revealed BCR/ABL1 fusion with p210 oncoprotein, establishing the diagnosis of chronic myelogenous leukemia in lymphoid blast crisis—a peculiar manifestation of a disease that usually manifests with significant leukocytosis.

Delayed Malaria Recrudescence and Relapse in the Setting of COVID-19 | Annals of Internal Medicine: Clinical Cases

It is unknown whether COVID-19 can trigger malaria recrudescence or relapse. Although Plasmodium falciparum recrudescence occurring years after infection is extremely rare, delayed Plasmodium vivax and Plasmodium ovale relapse from the latent hypnozoite stage is well described. We report a case of acute P falciparum and P ovale co-infection that occurred 2 weeks after COVID-19 in an otherwise immunocompetent patient living in a malaria nonendemic country and without exposure to malaria in the preceding 5 years. This case highlights a potential mechanism by which COVID-19–associated immune depletion and/or dysregulation may trigger a delayed presentation of malaria.

Hyperviscosity and Rouleaux Formation in Waldenstrom Macroglobulinemia | Annals of Internal Medicine: Clinical Cases

Waldenstrom macroglobulinemia is a distinct lymphoproliferative disorder resulting in excess production of IgM. Excess IgM and its subsequent pentameric formation may lead to the development of rouleaux and the hyperviscosity syndrome, an oncologic emergency typified by the presence of neurological changes. Plasmapheresis remains the therapy of choice for patients with the hyperviscosity syndrome, marked elevation of serum IgM, or serum viscosity, even in the absence of symptoms.

Massive Left Ventricular Aneurysm After Inferior Infarction | Annals of Internal Medicine: Clinical Cases

True ventricular aneurysm is a rare complication of myocardial infarction. After a 53-year-old man presented late with an inferior ST-segment elevation myocardial infarction, he was found to have a massive posterobasal left ventricular aneurysm. Cardiac magnetic resonance imaging volumetric analysis highlighted the hemodynamic significance of the aneurysm. As the result of persistent symptomatic heart failure, the patient underwent surgical resection of the aneurysm and placement of a pericardial patch with excellent results at follow-up.

Navigating Through the Complications of Chronic Immunosuppression in Transplant Patients | Annals of Internal Medicine: Clinical Cases

The advent of organ transplantation has given hope to patients with end-stage organ failure. Allograft rejection is a transplant complication and remains a significant cause of transplant-related morbidity and mortality. Successful transplantation is achieved with immunosuppression, and the discovery of newer immunosuppressive agents has provided transplant physicians with more effective medications in preventing allograft rejection. On the flip side, long-term immunosuppression is fraught with complications such as predisposition to infections, malignancies, and cardiovascular diseases. The patient presented in the case report developed a transplant-related lymphoma many years after his kidney and pancreatic transplant. Primary care providers should be aware of these complications and educate their patients on measures to prevent some of them.

Cryptococcal Meningoencephalitis in an HIV-Negative Host Infected With COVID-19: A Case Report | Annals of Internal Medicine: Clinical Cases

We report a rare case of cryptococcal infection in an immunocompetent adult who initially presented with altered sensorium and acute COVID-19 infection. The suspected diagnosis was encephalopathy due to pneumonia; however, the patient developed new neurologic deficits, warranting further investigation, which revealed cryptococcal meningoencephalitis. HIV testing was negative, but CD4 lymphocytopenia was seen, which resolved after treatment for both COVID-19 and cryptococcal meningoencephalitis. This case illustrates the importance of considering uncommon scenarios in which an opportunistic infection such as cryptococcal meningoencephalitis may present. It also demonstrates the need to frequently consider alternative diagnoses, particularly in the pandemic era.

Colitis Associated With Sevelamer Carbonate: A Case Report | Annals of Internal Medicine: Clinical Cases

Sevelamer carbonate is an anion-exchange, nonabsorbable resin that is commonly used to treat hyperphosphatemia in patients with advanced chronic kidney disease and end-stage renal disease. It is generally well-tolerated with only mild gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and constipation. There have been few case reports of gastrointestinal mucosal injury resulting from sevelamer crystal deposition. The severity of presentation varies from acute inflammation to polyp formation, necrosis, ulceration, and intestinal perforation. We report a 77-year-old woman with end-stage renal disease who was found to have mucosal injury from sevelamer crystal deposition resulting in colitis and ulceration.

Case of Ibuprofen-Induced Liver Injury | Annals of Internal Medicine: Clinical Cases

Drug-induced liver injury (DILI) resulting from nonsteroidal anti-inflammatory drugs (NSAIDs) is a rare phenomenon; however, several cases have been reported in the literature and the LiverTox database. For ibuprofen in particular, only 22 cases have been reported, and the mechanism for liver injury is unclear. In this report, we discuss a case of ibuprofen-induced liver injury to highlight the evaluation of NSAID-induced DILI, as well as the likely mechanism of injury.

Immune Checkpoint Inhibitor-Induced Polyarthritis: A Case Series | Annals of Internal Medicine: Clinical Cases

Immune checkpoint inhibitors (ICIs) have revolutionized cancer care; however, they are associated with ICI-related adverse events (ICI-AEs). Polyarthritis is a rare ICI-AE. Here we describe 2 patient cases of ICI-induced polyarthritis, induced by nivolumab/ipilimumab and sasanlimab for melanoma and urothelial cancer, respectively. Both patients had a medical history of nonrheumatological autoimmune disease, developed symptoms within 8 weeks of ICI, and had negative autoantibodies. Symptoms resolved with glucocorticoids. Neither patient discontinued their anticancer therapy. These cases add to the literature on ICI-induced polyarthritis. As ICIs become the standard of care, clinicians should familiarize themselves with their adverse effects.

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