Physical Activity in Type 2 Diabetes: Could One or Two Weekly Sessions Be Enough?

Palliative Care Educational App for Family Caregivers of Homebound Patients With Incurable Cancer: A Single-Center Randomized Trial: Annals of Internal Medicine: Vol 178, No 12

Background: Home-based palliative care relies on empowered family caregivers to overcome the limited availability of palliative care professional resources in managing incurable cancer. Objective: To explore whether adding a palliative care educational app to clinical palliative care could enhance health-related quality of life (HRQoL) in homebound patients with incurable cancer. Design: Single-center, open-label, individual randomized trial. (Chinese Clinical Trial Registry: ChiCTR2300077346) Setting: Single site in Shanghai, China. Participants: Patients with incurable cancer (aged ≥18 years; Karnofsky Performance Status ≤70) receiving palliative care along with consistent family caregivers (aged ≥18 years) enrolled between 28 July and 3 November 2023. Intervention: Patient–caregiver pairs were randomly assigned in a 1:1 ratio to either the intervention group (the app plus palliative care as usual [app]) or the control group (palliative care as usual). The app provided multimedia education on symptom and adverse effect management and nursing information for family caregivers. Measurements: The primary outcome was the mean between-group difference at month 2 in the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) score, with the summary score ranging from 0 to 100 and higher scores indicating better outcomes. The primary analysis used the intention-to-treat approach. Results: Of 154 randomly assigned pairs, 147 completed baseline assessments (intervention: n = 74; control: n = 73). The mean age of patients was 59.9 years, and 42.9% were female. At month 2, EORTC QLQ-C30 summary scores were 51.9 (95% CI, 45.4 to 58.5) in the intervention group and 35.7 (CI, 28.6 to 42.9) in the control group, with a mean difference of 16.2 (CI, 9.3 to 23.1). Limitations: Single-center design in China, Chinese-only WeChat app platform, unknown education levels of caregivers and patients, open-label design, and short 2-month follow-up with self-reported outcomes. Conclusion: The palliative care educational app through WeChat improved HRQoL among patients with incurable cancer at 2 months. This finding has implications for future study and development. Primary Funding Source: Shanghai Xingchuan Health Technology Co., Ltd.

In adults with clinically isolated syndrome suggestive of MS, high-dose vitamin D monotherapy reduced disease activity at 2 y

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

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder, with a prevalence of 4% to 10%. It is a chronic condition characterized by abdominal pain in conjunction with altered bowel habits, abdominal distention, or bloating. IBS can present with 3 different defecation patterns: IBS with constipation, IBS with diarrhea, or mixed IBS. Recent advances in IBS include a positive diagnosis based on symptom-based criteria and a treatment plan based on IBS subtype and bothersome symptoms. In addition to diet and lifestyle modifications, this article discusses the role of new pharmacologic and nonpharmacologic treatment options for the management of IBS.

The Prevalence and Characteristics of Difficult Patient Encounters: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 179, No 3

Background: Patients are sometimes experienced as difficult by their providers. Purpose: To estimate the prevalence of difficult patient encounters among adults being seen in nonpsychiatric settings. Secondary goals were to assess patient and provider characteristics associated with difficulty as well as patient outcomes. Data Sources: MEDLINE, Web of Science, SciELO, ProQuest, Theses, Scopus, PsycInfo, Cochrane Central Register of Controlled Trials, Global Index Medicus, and EMBASE (inception through 7 July 2025). Study Selection: In duplicate and independently. Data Extraction: Prevalence, patient characteristics (sex, mental health diagnosis, somatization, personality disorders, and chronic pain), provider characteristics (type of provider, encounter setting, burnout, years of experience, and sex), and encounter outcomes (patient unmet expectations and satisfaction) were extracted in duplicate. Data Synthesis: The prevalence of difficult encounters among clinic patients was 0.17 (95% CI, 0.15 to 0.19). Patient characteristics that increased difficulty included personality disorders (relative risk [RR], 2.2 [CI, 1.5 to 3.1]), depression (RR, 1.9 [CI, 1.7 to 2.2]), anxiety (RR, 2.1 [CI, 1.7 to 2.6]), and chronic pain (RR, 1.9 [CI, 1.5 to 2.4]). Providers with less experience (weighted mean difference, −3.5 years [CI, −5.0 to −1.9 years]) rated more encounters as difficult. Patients perceived as difficult were more likely to have unmet visit expectations (RR, 1.9 [CI, 1.4 to 2.5]) and lower satisfaction (RR, 0.76 [CI, 0.65 to 0.88]). Limitation: Limited data and heterogeneity for many secondary analyses. Conclusion: Providers perceived 17% of clinic patients as difficult. Patients perceived as difficult were more likely to have depression, anxiety, a greater number of symptoms, personality disorders, or chronic pain. Less experienced providers were more likely to judge patients as difficult. Patients from difficult encounters had more unmet visit expectations and less satisfaction. Primary Funding Source: None. (PROSPERO: CRD42024583715)

Correction: Previously Undisclosed Potential Conflict of Interest by an Author of American College of Physicians Performance Measure Papers

The Mediterranean Diet for Irritable Bowel Syndrome: A Randomized Clinical Trial: Annals of Internal Medicine: Vol 178, No 12

Background: Patients with irritable bowel syndrome (IBS) frequently seek dietary advice, but few evidence-based options exist. Major societal guidelines recommend traditional dietary advice (TDA) as first-line therapy, with the cumbersome and resource-intensive low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet reserved as second-line therapy. Recent pilot data suggest that the Mediterranean diet (MD), renowned for its general health benefits, improves IBS symptoms, but whether it can be considered another first-line dietary option is unknown. Objective: To determine if the MD is noninferior to TDA in managing IBS symptoms. Design: Randomized noninferiority clinical trial. (ClinicalTrials.gov: NCT05985018) Setting: Online virtual platform. Participants: 139 persons with IBS from across the United Kingdom. Intervention: 6 weeks of the MD (n = 68) or TDA (n = 71). Measurements: Primary end point was the proportion achieving clinical response, defined as 50-point or greater reduction in IBS Symptom Severity Scale (IBS-SSS). Secondary outcomes included changes in IBS-SSS scores, psychological health, somatic symptom reporting, quality of life, diet satisfaction, and Mediterranean Diet Adherence Screener (MEDAS). Results: Baseline characteristics (mean age, 40.4 years [range, 19 to 65 years]; 80% women) and IBS-SSS (mean, 309 [SD, 90]) were similar between groups. On modified intention-to-treat analysis, the primary end point was met by 62% (95% CI, 50% to 73%) following a MD versus 42% (CI, 31% to 55%) following TDA. The difference in clinical response favored the MD (difference, 20 percentage points [CI, 4 to 36 percentage points]; P = 0.017), demonstrating noninferiority and superiority. There was a greater reduction in the mean IBS-SSS after a MD than TDA (−101.2 vs. −64.5; Δ−36.7 [CI,−70.5 to −2.8]; P = 0.034). No statistically significant differences were seen between the groups with regard to changes in mood, somatic symptoms, quality of life, or diet satisfaction. The MEDAS significantly increased after a MD compared with TDA (P < 0.001). Limitation: No long-term data. Conclusion: The MD showed noninferiority and superiority to TDA in managing IBS symptoms. It represents a viable first-line dietary intervention for IBS. Primary Funding Source: None.

Statins May Be Necessary but Are Not Sufficient for People Aging With HIV

Annals Video Summary - Associations Between Unconditional Cash Transfers and Postpartum Outcomes in the United States: A Systematic Review

Effectiveness of Sodium–Glucose Cotransporter-2 Inhibitors Versus Glucagon-like Peptide-1 Receptor Agonists on Diabetic Foot Disease: An Emulated Target Trial: Annals of Internal Medicine: Vol 179, No 3

Background: The effects of sodium–glucose cotransporter-2 inhibitors (SGLT-2is) on diabetic foot disease have been mixed in prior trials of SGLT-2is compared with placebo. The comparative risk for diabetic foot disease with SGLT-2is compared with glucagon-like peptide-1 receptor agonists (GLP-1RAs) is unknown. Objective: To compare risks for foot disease in new users of SGLT-2is and GLP-1RAs. Design: Cohort study using target trial emulation. Setting: Danish population-based study. Participants: Patients with type 2 diabetes initiating SGLT-2i or GLP-1RA treatment, identified using national health care registry data from 2013 to 2023, and a convenience sample enrolled in a research cohort study with additional behavioral and clinical assessments. Measurements: Incident diagnosis of foot disease outcomes (peripheral neuropathy, peripheral artery disease, foot ulcers, or lower-limb amputation) as defined by the International Working Group on the Diabetic Foot. Inverse probability of treatment–weighted risk ratios (RRs) were estimated, with adjustment for 45 demographic, clinical, and other factors. Results: The registry cohort included 53 769 new users of SGLT-2is and 30 380 of GLP-1RAs. During 6 years of follow-up, any foot disease occurred in 10.8% of SGLT-2i users and 12.0% of GLP-1RA users, corresponding to an RR of 0.90 (95% CI, 0.84 to 0.97) in an intention-to-treat analysis; differences did not emerge until after year 3, when 40% of SGLT-2i users and 32% of GLP-1RA users had discontinued initial treatment. The modest reduction in risk among SGLT-2i users was driven by lower risk for neuropathy (RR, 0.78 [CI, 0.68 to 0.87]). Users of SGLT-2is and GLP-1RAs had similar risks for peripheral artery disease, foot ulcers, amputations, and all-cause mortality. Limitation: Residual confounding; exposure and outcome misclassification. Conclusion: New SGLT-2i users had a modestly lower risk for foot disease largely driven by a lower risk for neuropathy than GLP-1RA users. Primary Funding Source: Aarhus University and Center for Population Medicine.