ACP Letter to Congressional Leaders Sharing Our Priorities for Telehealth in the 117th Congress

ACP Letter to Congress in Support of the George Floyd Policing Act of 2021

ACP Comment Letter to CMS on the Patient Protection and Affordable Care Act Notice of Benefit and Payment Parameters for PY 2027

ACP Comment Letter on Senate Finance Committee Chronic Care Policy Options

ACP Comments to the Department of Treasury on Section 213 of the Internal Revenue Code

ACP Comments re CMS Episode-Based Cost Measure Development for MACRA/QPP

ACP Comments on Department of Health and Human Services (HHS) Proposed Rule to Update Section 1557

ACP Comment Letter to the Senate Finance Committee Regarding Tele-Mental Health Draft Legislation

ACP letter to CMS, regarding the CY 2014 Medicare Physician Fee Schedule

ACP Comment Letter on the Occupational Safety and Health Administration's Heat Injury and Illness Prevention in Outdoor and Indoor Work Settings Proposed Rule

Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes

Description: The American Diabetes Association (ADA) annually updates 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 2017 Standards of Care, the ADA Professional Practice Committee did MEDLINE searches from 1 January 2016 to November 2016 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 of Care 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. Recommendation: This synopsis focuses on recommendations from the 2017 Standards of Care about monitoring and pharmacologic approaches to glycemic management for type 1 diabetes.

Individualized Glycemic Control for U.S. Adults With Type 2 Diabetes: A Cost-Effectiveness Analysis: Annals of Internal Medicine: Vol 168, No 3

Background: Intensive glycemic control in type 2 diabetes (glycated hemoglobin [HbA1c] level <7%) is an established, cost-effective standard of care. However, guidelines recommend individualizing goals on the basis of age, comorbidity, diabetes duration, and complications. Objective: To estimate the cost-effectiveness of individualized control versus uniform intensive control (HbA1c level <7%) for the U.S. population with type 2 diabetes. Design: Patient-level Monte Carlo–based Markov model. Data Sources: National Health and Nutrition Examination Survey 2011–2012. Target Population: The approximately 17.3 million persons in the United States with diabetes diagnosed at age 30 years or older. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: Individualized versus uniform intensive glycemic control. Outcome Measures: Average lifetime costs, life-years, and quality-adjusted life-years (QALYs). Results of Base-Case Analysis: Individualized control saved $13 547 per patient compared with uniform intensive control ($105 307 vs. $118 854), primarily due to lower medication costs ($34 521 vs. $48 763). Individualized control decreased life expectancy (20.63 vs. 20.73 years) due to an increase in complications but produced more QALYs (16.68 vs. 16.58) due to fewer hypoglycemic events and fewer medications. Results of Sensitivity Analysis: Individualized control was cost-saving and generated more QALYs compared with uniform intensive control, except in analyses where the disutility associated with receiving diabetes medications was decreased by at least 60%. Limitation: The model did not account for effects of early versus later intensive glycemic control. Conclusion: Health policies and clinical programs that encourage an individualized approach to glycemic control for U.S. adults with type 2 diabetes reduce costs and increase quality of life compared with uniform intensive control. Additional research is needed to confirm the risks and benefits of this strategy. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.

Pharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes

Description: The American Diabetes Association (ADA) annually updates the 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 2017 Standards, the ADA Professional Practice Committee updated previous MEDLINE searches performed from 1 January 2016 to November 2016 to add, clarify, or revise recommendations based on new evidence. The committee rates 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 recommendations from the 2017 Standards about pharmacologic approaches to glycemic treatment of type 2 diabetes.

Glycemic Therapy for Type 2 Diabetes: Choices Expand, Data Lag Behind

Balancing Primary Diabetes Care Quality and Services

Pioglitazone: An Addition to Our Toolbox for Patients With Diabetes and Nonalcoholic Steatohepatitis?

Should We Screen for Type 2 Diabetes?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 165, No 7

The prevalence of diabetes in the United States is rising. Twelve percent of U.S. adults have diabetes and another 37% have impaired fasting glucose or impaired glucose tolerance. Diabetes is a major risk factor for such outcomes as cardiovascular disease, blindness, chronic kidney disease, and limb amputation. An important consideration is whether screening for abnormal glucose levels or diabetes reduces cardiovascular or all-cause morbidity and mortality. In October 2015, the U.S. Preventive Services Task Force published recommendations on screening for abnormal blood glucose and concluded that intensive lifestyle interventions have a moderate benefit in reducing progression to diabetes in patients who have abnormal blood glucose levels detected by screening. It found inadequate evidence that such screening reduces cardiovascular or all-cause mortality and no evidence of psychological or other harms from screening. The Task Force recommends glucose screening every 3 years for adults aged 40 to 70 years who are overweight or obese and do not have symptoms of diabetes. In this article, we present the case of a man who meets these criteria and explore his preferences and concerns regarding screening. Two experts then debate screening merits and benefits, the significance of abnormal blood glucose levels and diabetes as cardiovascular risk factors, and application of the guidelines to this particular patient.

Primary Care Physician Volume and Quality of Diabetes Care: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 166, No 4

Background: A relationship between higher patient volume and both better quality of care and better outcomes has been shown for many acute care conditions. Whether a volume–quality relationship exists for the outpatient management of chronic diseases is uncertain. Objective: To explore the association between primary care physician volume and quality of diabetes care. Design: Cohort study. Setting: The study was conducted using linked population-based health care administrative data in Ontario, Canada. Patients: 1 018 647 adults with diabetes in 2011 who received care from 9014 primary care physicians. Two measures of volume were ascertained for each physician: overall ambulatory volume (representing time available to devote to chronic disease management during patient encounters) and diabetes-specific volume (representing disease-specific expertise). Measurements: Quality of care was measured over a 2-year period using 6 indicators: disease monitoring (eye examination, hemoglobin A1c testing, and low-density lipoprotein cholesterol testing), prescribing appropriate medications (angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers and statins), and adverse clinical outcomes (emergency department visits for hypoglycemia or hyperglycemia). Results: Higher overall ambulatory volume was associated with lower rates of appropriate disease monitoring and medication prescription. In contrast, higher diabetes-specific volume was associated with better quality of care across all 6 indicators. Limitation: Only a select set of quality indicators and potential confounders could be ascertained from available data. Conclusion: Primary care physicians with busier ambulatory patient practices delivered lower-quality diabetes care, but those with greater diabetes-specific experience delivered higher-quality care. These findings show that relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care. Health policies or programs to support physicians with a low volume of patients with diabetes may improve care. Primary Funding Source: Canadian Institutes of Health Research.

Physical Fitness and Risk for Type 2 Diabetes Mellitus: Reducing Risk at Any Weight

Reporting of Sex Effects by Systematic Reviews on Interventions for Depression, Diabetes, and Chronic Pain

Systematic reviews (SRs) have the potential to contribute uniquely to the evaluation of sex and gender differences (termed “sex effects”). This article describes the reporting of sex effects by SRs on interventions for depression, type 2 diabetes mellitus, and chronic pain conditions (chronic low back pain, knee osteoarthritis, and fibromyalgia). It includes SRs published since 1 October 2009 that evaluate medications, behavioral interventions, exercise, quality improvement, and some condition-specific treatments. The reporting of sex effects by primary randomized, controlled trials is also examined. Of 313 eligible SRs (86 for depression, 159 for type 2 diabetes mellitus, and 68 for chronic pain), few (n = 29) reported sex effects. Most SRs reporting sex effects used metaregression, whereas 9 SRs used subgroup analysis or individual-patient data meta-analysis. The proportion of SRs reporting the sex distribution of primary studies varied from a low of 31% (n = 8) for low back pain to a high of 68% (n = 23) for fibromyalgia. Primary randomized, controlled trials also infrequently reported sex effects, and most lacked an adequate sample size to examine them. Therefore, all SRs should report the proportion of women enrolled in primary studies and evaluate sex effects using appropriate methods whenever power is adequate.

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.

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.