Using Innovation to Reform Medicare Physician Payment

Formularies and Pharmacy Benefit Management, Reinventing Managed Care Series

The Paperless Medical Office: Digital Technology's Potential for the Internist

Ambulatory Care Formularies and Pharmacy Benefit Management by Managed Care Organizations

Approaches to Address the Sustainable Growth Rate (SGR)

ACP response letter to the April 27, 2012 request by the U.S. House of Representatives Committee on Ways and Means to offer input on physician payment reforms, May 23, 2012

ACP Response to SFC on Chronic Care Policies

ACP's Comments regarding ONC's Draft Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs

ACP Comments on National Academies" (NASEM) Call for Federal Policies that Contribute to Racial and Ethnic Health Inequities

ACP Comment Letter Regarding the Physician Fee Schedule Proposed Rule for CY 2016

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.

Physical Fitness Among Swedish Military Conscripts and Long-Term Risk for Type 2 Diabetes Mellitus: A Cohort Study: Annals of Internal Medicine: Vol 164, No 9

Background: Early-life physical fitness has rarely been examined in relation to type 2 diabetes mellitus (DM) in adulthood because of the lengthy follow-up required. Elucidation of modifiable risk factors at young ages may help facilitate earlier and more effective interventions. Objective: To examine aerobic capacity and muscle strength at age 18 years in relation to risk for type 2 DM in adulthood. Design: National cohort study. Setting: Sweden. Participants: 1 534 425 military conscripts from 1969 to 1997 (97% to 98% of all men aged 18 years nationwide) without prior type 2 DM. Measurements: Aerobic capacity and muscle strength (measured in watts and newtons per kilogram of body weight, respectively) were examined in relation to type 2 DM identified from outpatient and inpatient diagnoses from 1987 to 2012 (maximum age, 62 years). Results: 34 008 men were diagnosed with type 2 DM in 39.4 million person-years of follow-up. Low aerobic capacity and muscle strength were independently associated with increased risk for type 2 DM. The absolute difference in cumulative incidence of type 2 DM between the lowest and highest tertiles of both aerobic capacity and strength was 0.22% at 20 years of follow-up (95% CI, 0.20% to 0.25%), 0.76% at 30 years (CI, 0.71% to 0.81%), and 3.97% at 40 years (CI, 3.87% to 4.06%). Overall, the combination of low aerobic capacity and muscle strength was associated with a 3-fold risk for type 2 DM (adjusted hazard ratio, 3.07 [CI, 2.88 to 3.27]; P < 0.001), with a positive additive interaction (P < 0.001). These associations were seen even among men with normal body mass index. Limitation: This cohort did not include women and did not measure physical fitness at older ages. Conclusion: In this large cohort of Swedish male military conscripts, low aerobic capacity and muscle strength at age 18 years were associated with increased long-term risk for type 2 DM, even among those with normal body mass index. Primary Funding Source: National Institutes of Health.

Prevalence and Management of Obesity in U.S. Adults With Type 1 Diabetes

Prevalence and Management of Obesity in U.S. Adults With Type 1 Diabetes

Vitamin D and Risk for Type 2 Diabetes in People With Prediabetes

Vitamin D and Risk for Type 2 Diabetes in People With Prediabetes

First-Line Therapy for Type 2 Diabetes With Sodium–Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists

First-Line Therapy for Type 2 Diabetes With Sodium–Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists

First-Line Therapy for Type 2 Diabetes With Sodium–Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists

An Unusual Cause of Acute Abdominal Pain: A Case Report and Review of the Diagnostic Reasoning | Annals of Internal Medicine: Clinical Cases

Spontaneous bladder rupture is a rare cause of acute abdominal pain. This case report reviews the clinical presentation of a patient with this unusual disorder and discusses the steps that the clinician used to reach the diagnosis. The concept of how clinicians use problem representations and illness scripts to arrive at a differential diagnosis, and ultimately a diagnosis, is discussed.

Metastatic Lobular Carcinoma of the Breast Masquerading as Gallstone Disease – A Case Report | Annals of Internal Medicine: Clinical Cases

The gallbladder is a rare site of breast cancer metastasis. We report the patient case of a 60-year-old woman with isolated metastasis to the gallbladder, which was surgically removed for symptomatic cholelithiasis, with a subsequent new diagnosis of infiltrating lobular carcinoma (ILC) of the breast. ILC tends to metastasize to unusual sites such as the gastrointestinal and genitourinary tracts, but these usually occur concurrently with other more common sites of distant metastasis such as the bone, lungs, and liver. Our case underscores the need for routine histologic examination of gallbladder after cholecystectomy.

Point-of-Care Ultrasound: An Emerging Tool for Diagnosing Calciphylaxis | Annals of Internal Medicine: Clinical Cases

Calciphylaxis is a disease involving medial calcification of dermal arterioles, resulting in cutaneous necrosis. Diagnosis is typically clinical, but it is frequently misdiagnosed. Skin biopsy, the gold standard diagnostic test, is hindered by risk, patient refusal, and difficulties with histologic evaluation. This case series investigates using soft tissue point-of-care-ultrasound (POCUS) to aid in diagnosis. It describes ultrasound images obtained from patients diagnosed with calciphylaxis. These potentially pathognomonic sonographic findings in the proper clinical context include superficial hyperechoic foci lining small-caliber vessels with posterior acoustic shadowing. This demonstrates the diagnostic potential of POCUS in evaluating patients with possible calciphylaxis.

A Case of DILI and Subsequent HLH Induced by Allopurinol | Annals of Internal Medicine: Clinical Cases

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome that occurs because of uncontrolled immune cell activation and can present as a primary or acquired disorder. It is an illness with a high mortality rate that has been increasing in incidence over the past decade. There are few reports of allopurinol-induced HLH. This case describes a patient who was initially diagnosed with drug-induced liver injury secondary to allopurinol and subsequently diagnosed with HLH secondary to allopurinol. The discussion highlights the pathophysiology, clinical findings, diagnostic work-up, and treatment of HLH, along with mentioning interventions that focus on prevention of these diseases.

Chronic Lymphocytic Leukemia Involving the Liver Without High-Grade Transformation | Annals of Internal Medicine: Clinical Cases

Chronic lymphocytic leukemia is most frequently encountered among the elderly population. Hepatic infiltration may be present at the time of diagnosis, but significant extranodal involvement rarely occurs without high-grade transformation. Abnormal liver enzymes have important prognostic implications in terms of staging the disease and initiating treatment. We describe an atypical presentation of chronic lymphocytic leukemia in a patient who presented with rising liver enzyme levels, extensive hepatic infiltration, and portal hypertension but with no evidence of high-grade transformation on liver biopsy.

Blastomycosis Pneumonia as an Unusual Cause of Horner Syndrome: Case Report and Review | Annals of Internal Medicine: Clinical Cases

We describe an immunocompetent patient with Horner syndrome secondary to invasive Blastomyces pneumonia and provide a review of the rare infectious etiologies of this syndrome. To our knowledge, this is the first published human case report of Horner syndrome secondary to Blastomyces pneumonia.

Osteomyelitis Pubis After Initiation of an SGLT2 Inhibitor | Annals of Internal Medicine: Clinical Cases

Osteomyelitis pubis is a rare infectious entity that is often misdiagnosed. Early clinical suspicion and appropriate diagnostic workup are required to prevent a delay in diagnosis and to differentiate the disease from alternative noninfectious diagnoses such as osteitis pubis. Herein, we report a case of osteomyelitis pubis with delayed diagnosis in a patient who recently initiated an SGLT2 inhibitor before the onset of symptoms. The effect of SGLT2 inhibitors on the risk of this disease is unknown but may warrant further investigation, as this case highlights.

Colon Perforation in the Setting of Sevelamer Crystals | Annals of Internal Medicine: Clinical Cases

Sevelamer is frequently used as a phosphate binder in patients with end-stage renal disease. It can also cause gastrointestinal side effects including colitis, obstruction, and, rarely, perforation.

Rumpel-Leede Phenomenon | Annals of Internal Medicine: Clinical Cases

We report a case of Rumpel-Leede phenomenon in an 80-year-old man presenting in the context of lightheadedness, dizziness, and elevated at-home blood pressure readings. In this case, the finding was found quite incidentally, by a routine blood pressure measurement, and was characterized by a purpuric rash on both upper extremities, which was nonpalpable and nonblanching with pressure. The pathophysiology of this rare clinical entity involves acute rupture of dermal capillaries from capillary fragility, resulting in a self-limiting nonpurpuric rash that resolves spontaneously without intervention.

Acute Lower-Extremity Posterior Compartment Syndrome: A Rare Complication of Apixaban Use | Annals of Internal Medicine: Clinical Cases

Apixaban is an oral anticoagulant that directly inhibits factor Xa and is indicated for the prophylaxis and treatment of deep venous thrombosis and stroke prevention in nonvalvular atrial fibrillation. Acute lower-extremity posterior compartment syndrome is a rare complication of apixaban use. We present a 78-year-old man with significant medical morbidities taking apixaban for atrial fibrillation presenting with posttraumatic extensive hemorrhagic bullae on the left proximal pretibial region secondary to anticoagulation. We recommend that clinicians develop awareness of the potential for serious bleeding complications of anticoagulants and devise strategies to identify the need for early recognition and prompt management.