Giant Cell Arteritis

Giant cell arteritis is a relapsing large-vessel vasculitis affecting the aorta and its branches. It is the most common vasculitis in persons 50 years of age and older. Vision loss occurs in 18% of patients and is preventable with prompt recognition, evaluation, and treatment. Large-artery complications include stenosis, aortic aneurysms, or dissections. Glucocorticoid therapy is effective, but nearly 50% of patients experience relapse. Tocilizumab and upadacitinib are efficacious glucocorticoid-sparing therapies. Patients require long-term monitoring for aortic aneurysms, a late disease complication, even after therapy is discontinued.

How Would You Manage This Patient With Frequent Migraine Headaches? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Migraine headaches are highly prevalent and, for women below the age of 50, the leading cause of years lived with disability. Migraines disproportionately affect persons of lower socioeconomic status and those who are uninsured, and they result in millions of office and emergency department visits annually. Migraines are also responsible for billions of dollars in lost productivity and health care expenses each year. Medication classes traditionally used for migraine headache treatment have included nonsteroidal anti-inflammatory drugs, acetaminophen, antihypertensive drugs, antiseizure drugs, antidepressant drugs, and botulinum toxin. In recent years, triptans have come into widespread use for acute treatment, and calcitonin gene-related peptide antagonists, including gepants and monoclonal antibodies, have been used for both acute treatment and prevention. In 2025, the International Headache Society and the American College of Physicians published guidelines on pharmacotherapy for migraine headaches covering both acute and preventive treatments. Here, 2 experts in this field, a primary care physician and a neurologist and headache specialist, debate how to manage the case of a patient with frequent migraine headaches. They discuss the diagnostic considerations and the acute and preventive treatment challenges in the care of this population.

Methodological Approaches to Real-World Evidence Generation for Glucagon-like Peptide-1–Based Therapies: Synopsis of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have reshaped the clinical approach to managing obesity and type 2 diabetes. As approved indications have expanded, use of GLP-1RAs has increased rapidly in the United States. Although randomized trials demonstrate strong efficacy, many questions remain about their optimal use in clinical practice. Real-world data (RWD) from electronic health records, registries, insurance claims, and other sources offer a promising avenue to address these questions. However, concerns about data quality, selection bias, and incomplete ascertainment of medication use and outcomes pose significant challenges to the validity of the resulting evidence. In May 2025, the National Institute of Diabetes and Digestive and Kidney Diseases convened experts from regulatory agencies, payer organizations, and academia to explore these challenges. This second of 2 synopsis articles on the workshop summarizes the discussion around the strengths and limitations of various RWD sources and methodological approaches to strengthen causal inference and generalizability. Presenters highlighted pragmatic clinical trials and target trial emulation as strategies to generate stronger real-world evidence (RWE) that is relevant to both clinical practice and policy. The workshop underscored that careful attention to study design, data limitations, and analytic approach is essential to yield RWE that informs clinicians, patients, payers, and policymakers.

Comparison of Initial Artificial Intelligence (AI) and Final Physician Recommendations in AI-Assisted Virtual Urgent Care Visits

Expanding Technology-Enabled, Nurse-Delivered Chronic Disease Care: A Pragmatic, Randomized, Effectiveness–Implementation Trial: Annals of Internal Medicine: Vol 179, No 7

Background: Comprehensive telehealth is used effectively for treatment-resistant chronic diseases in certain integrated health systems but has seldom been implemented in systems that provide mainly fee-for-service (FFS) care. Objective: To examine the effectiveness and implementation of comprehensive telehealth delivered in an FFS environment for patients with uncontrolled type 2 diabetes (T2D) and comorbid hypertension. Design: Pragmatic, randomized, effectiveness–implementation trial. (ClinicalTrials.gov: NCT05120544) Setting: 6 academic primary care or endocrinology clinics. Participants: Participants had both T2D with hemoglobin A1c (HbA1c) persistently at 8.0% or higher for at least 6 months and hypertension with at least 1 systolic blood pressure (BP) above 140 mm Hg or diastolic BP above 90 mm Hg in the past year. Intervention: Two 12-month, mobile monitoring–enabled interventions: a self-monitoring control program and a nurse-delivered, comprehensive telehealth program incorporating self-management support and medication management. Measurements: Primary (HbA1c) and secondary outcomes were evaluated at 12 months. Implementation analyses evaluated fidelity and barriers to intervention delivery. Results: Participants were 64% female and 68% Black. The mean age was 54.5 years, mean HbA1c 9.8%, and mean BP 135/81 mm Hg. The estimated mean change in HbA1c from 0 to 12 months was −0.7 percentage points with self-monitoring and −1.1 percentage points with comprehensive telehealth; the estimated mean between-group difference in HbA1c change at 12 months was −0.4 percentage points (95% CI, −1.0 to 0.3 percentage points). Between-group differences in change in secondary outcomes did not reach statistical significance, except for diabetes self-care (0.4 [CI, 0.0 to 0.9], favoring comprehensive telehealth). The comprehensive program was delivered with suboptimal fidelity (median encounters per participant, 9; fidelity threshold, ≥12); analyses identified barriers to program delivery. Limitation: Generalizability to dissimilar populations and systems lacking telehealth infrastructure may be limited. Conclusion: Comprehensive telehealth did not substantially lower HbA1c relative to control in this study. Population factors, intervention and control program design, and barriers to FFS implementation of comprehensive telehealth may have contributed to these findings. Primary Funding Source: National Institute of Nursing Research and Duke Clinical & Translational Science Institute.

Initiation of Medications for Alcohol Use Disorder Among Hospitalized Veterans: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 179, No 6

Background: Hospitalization for alcohol use disorder (AUD) offers an opportunity to initiate evidence-based medications for alcohol use disorder (MAUDs). Objective: To describe patterns and factors associated with hospital initiation of MAUD. Design: Retrospective cohort study. Setting: Veterans Health Administration (VHA). Participants: Veterans hospitalized with a primary diagnosis of AUD in 2022 or 2023. Measurements: Patients had MAUD initiated as an inpatient or within 7 days of discharge. Logistic regression models estimated the predicted probabilities of MAUD initiation based on hospital fixed effects and demographic and clinical characteristics. Results: Among 29 041 hospitalizations for AUD of veterans without MAUD at baseline in 142 hospitals (median age, 55 years; 94% male), in 8932 hospitalizations (30.8%), MAUD was initiated as an inpatient or within 7 days; MAUDs were naltrexone (57.9%), acamprosate (16.5%), and injectable naltrexone (13.9%). Of MAUD initiations, 6221 (69.6%) were during an inpatient stay and the rest were within 7 days. Of the 6221 inpatient initiations, 97.7% had a prescription for MAUD within 30 days after discharge. In adjusted analyses, MAUD initiation was more likely for hospitalizations with a specialty addiction consultation and those receiving psychiatry versus medicine service. Initiation of MAUD was less likely for persons aged 65 years or older, men, American Indian or Alaska Native versus White veterans, frail veterans, veterans diagnosed with opioid use disorder, and those in the intensive care unit. The median hospital-level rate of MAUD initiation was 29.9% (IQR, 22.6% to 36.3%). Limitation: Generalizability to other health care systems. Conclusion: Within the VHA, 30% of hospitalizations for AUD resulted in MAUD initiation as an inpatient or within 7 days of discharge, with substantial variation across hospitals and patient demographic and clinical factors. These data indicate a need to identify and disseminate successful hospital-based strategies to increase prescribing of MAUD. Primary Funding Source: U.S. Department of Veterans Affairs and National Institute on Aging.

Benzodiazepine Prescriptions to Older Adults in the United States, 2015 to 2024

Atopic Dermatitis

Atopic dermatitis affects approximately 10% of the U.S. population and is more common in children than adults. Up to 99% of physician visits for atopic dermatitis are in primary care. Most cases can be managed successfully with topical treatments, including moisturizers and prescription anti-inflammatory treatments, such as corticosteroids, calcineurin inhibitors, phosphodiesterase-4 inhibitors, Janus kinase (JAK) inhibitors, and aryl hydrocarbon receptor agonists. For more refractory or severe atopic dermatitis, ultraviolet phototherapy and systemic treatments, usually prescribed by specialists, can be used. Systemic treatments include older off-label immunomodulators, such as methotrexate. Since 2017, multiple on-label injectable biologics and oral JAK inhibitors have been approved.

In hypertension with high CV risk, intensive vs. standard BP-lowering therapy improved HRQoL by a small amount at a median 3.4 y

Clinical Impact Ratings GIM/FP/GP: 6 out of 7 Cardiology: 5 out of 7

Small Acts of Compassion: What Current Evidence Does Not Measure