<p> </p> <p>Traditionally, the prevention and management of chronic complications in individuals with type 1 (T1D) and type 2 diabetes (T2D) has been focused on of nephropathy, retinopathy, neuropathy, and atherosclerotic cardiovascular disease (including ischemic heart disease, stroke or peripheral vascular disease) (1). However, heart failure (HF) has been recognized as a common complication of diabetes, with a prevalence of up to 22% in individuals with diabetes and increasing incidence rates (2–4). This recognition stems in part from trials focused on cardiovascular safety of newer drugs to treat diabetes. Data also suggest HF may develop in individuals with diabetes even in the absence of hypertension, coronary heart disease, or valvular heart disease and, as such, represents a major cardiovascular complication in this vulnerable population (5). Given that during the past decade, the prevalence of diabetes (particularly T2D) has risen by 30% globally (6) (with prevalence expected to increase further), the burden of HF on the health care system will continue to rise.</p> <p>The scope of this American Diabetes Association (ADA) consensus report with designated representation from the American College of Cardiology (ACC) is to provide clear guidance and to recommend best approaches to general internists, family physicians, and endocrinologists for HF screening, diagnosis, and management in individuals with T1D, T2D, or prediabetes to mitigate the risks of serious complications, leveraging prior policy statements by the ACC (7) and American Heart Association (AHA) (2). This consensus report was developed by the writing group convened by ADA with representation from ACC through a series of conference calls, emails, and independent work from March 2021 through March 2022. </p> <p>Traditionally, the prevention and management of chronic complications in individuals with type 1 (T1D) and type 2 diabetes (T2D) has been focused on of nephropathy, retinopathy, neuropathy, and atherosclerotic cardiovascular disease (including ischemic heart disease, stroke or peripheral vascular disease) (1). However, heart failure (HF) has been recognized as a common complication of diabetes, with a prevalence of up to 22% in individuals with diabetes and increasing incidence rates (2–4). This recognition stems in part from trials focused on cardiovascular safety of newer drugs to treat diabetes. Data also suggest HF may develop in individuals with diabetes even in the absence of hypertension, coronary heart disease, or valvular heart disease and, as such, represents a major cardiovascular complication in this vulnerable population (5). Given that during the past decade, the prevalence of diabetes (particularly T2D) has risen by 30% globally (6) (with prevalence expected to increase further), the burden of HF on the health care system will continue to rise.</p> <p>The scope of this American Diabetes Association (ADA) consensus report with designated representation from the American College of Cardiology (ACC) is to provide clear guidance and to recommend best approaches to general internists, family physicians, and endocrinologists for HF screening, diagnosis, and management in individuals with T1D, T2D, or prediabetes to mitigate the risks of serious complications, leveraging prior policy statements by the ACC (7) and American Heart Association (AHA) (2). This consensus report was developed by the writing group convened by ADA with representation from ACC through a series of conference calls, emails, and independent work from March 2021 through March 2022. </p>
BackgroundObservational studies have linked proton pump inhibitors (PPIs) with serious adverse effects. The study aimed to evaluate internists’ perceptions of PPI harms and effects on prescribing.MethodsThis was an online survey of a representative sample of the American College of Physicians in 2013. We queried familiarity with and concern about PPI adverse effects (1 - 7 Likert-type scales, anchored by “not at all” and “extremely”). We also asked how frequently (often, sometimes, rarely, or never) participants used any of three “de-escalation” strategies to stop or reduce PPIs because of concern about adverse effects: reducing patients’ PPI dose, switching to H2 blocker, or discontinuing PPI. We used multivariable logistic regression to evaluate associations between sometimes/often using any PPI de-escalation strategy and gender, time in practice, familiarity, and concern.ResultsThe response rate was 53% (487/914). Seventy percent were male, median time in practice was 11 - 15 years, and most practiced general medicine (58%). Ninety-nine percent reported at least some familiarity with reported adverse effects (mean 4.9, standard deviation (SD) 1.0), and 98% reported at least some concern (mean 4.6, SD 1.3). Sixty-three percent reported sometimes/often reducing the PPI dose, 52% switching to H2 blocker, and 44% discontinuing PPI. In multivariable analysis, familiarity with adverse effects (OR 1.66 (1.31 - 2.10) for 1-point increase, P < 0.001) and concern (OR 2.14 (1.76 - 2.61) for 1-point increase, P < 0.001) were independently associated with de-escalation. Gender and time in practice had no effects.ConclusionAlmost all internists report awareness and concern about PPI adverse effects, and most are de-escalating PPIs as a result. Research on which approach is most effective for which patients is critically important.
Background: Primary care providers (PCPs) are expected to help patients with obesity to lose weight through behavior change counseling and patient-centered use of available weight management resources. Yet, many PCPs face knowledge gaps and clinical time constraints that hinder their ability to successfully support patients’ weight loss. Fortunately, a small and growing number of physicians are now certified in obesity medicine through the American Board of Obesity Medicine (ABOM) and can provide personalized and effective obesity treatment to individual patients. Little is known, however, about how to extend the expertise of ABOM-certified physicians to support PCPs and their many patients with obesity. Aim: To develop and pilot test an innovative care model – the Weight Navigation Program (WNP) – to integrate ABOM-certified physicians into primary care settings and to enhance the delivery of personalized, effective obesity care. Methods: Quality improvement program with an embedded, 12-month, single-arm pilot study. Patients with obesity and ≥1 weight-related co-morbidity may be referred to the WNP by PCPs. All patients seen within the WNP during the first 12 months of clinical operations will be compared to a matched cohort of patients from another primary care site. We will recruit a subset of WNP patients (n = 30) to participate in a remote weight monitoring pilot program, which will include surveys at 0, 6, and 12 months, qualitative interviews at 0 and 6 months, and use of an electronic health record (EHR)-based text messaging program for remote weight monitoring. Discussion: Obesity is a complex chronic condition that requires evidence-based, personalized, and longitudinal care. To deliver such care in general practice, the WNP leverages the expertise of ABOM-certified physicians, health system and community weight management resources, and EHR-based population health management tools. The WNP is an innovative model with the potential to be implemented, scaled, and sustained in diverse primary care settings.
INTRODUCTION: Transgender people face multiple barriers to accessing needed healthcare. Use of nonprescription hormones for gender affirmation may pose significant health risks. We aim to assess systemic factors affecting nonprescription hormone use among transgender people. METHODS: We used data from the United States Transgender Survey, a large convenience sample of 27,000 transgender adults in the U.S., collected between August and September of 2015. Respondents who indicated that they were currently taking gender affirming hormones and were not on active military duty were included in the study (n =12,095). Weighted multivariable logistic regression and predictive margins were used to generate odds ratios. RESULTS: Of 12,095 people who were using gender affirming hormones and were not on active military duty, 9.36% (n=1,000) were receiving hormones from sources other than a licensed professional, and 19.71% (n=2,536) reported denial of hormone coverage by insurance. The odds of using nonprescription hormones was higher among transfeminine respondents (OR 5.08, 95% CI 3.44-7.51, P < 0.001), Asian and multiracial-identified respondents, those who were uninsured, who had negative experiences when accessing care (OR 1.58, 95% CI 1.06-2.36, P= 0.026), and those who were denied insurance coverage (OR 2.54, 95% CI 1.64-3.94, P<0.001). CONCLUSION: Barriers to accessing affirming care and to coverage of treatment were associated with increased risk of non-prescription hormone use. Future research is needed to explore potential interventions to decrease non-prescription use and its potential harms, such as coverage of hormone therapy, provider trainings, and harm-reduction strategies.
Behavioral lifestyle interventions in the community setting are effective in reducing the risk and burden of chronic diseases. The promotion and implementation of physical activity plays a key role in these community-based lifestyle programs. New guidelines on preparticipation screening for cardiovascular disease before physical activity have been released which include substantive modifications. These updated recommendations represent a substantial paradigm shift toward a more liberal approach that results in fewer individuals needing to seek medical clearance before starting a physical activity program. This shift has significant implications for those promoting physical activity within the community setting. The objectives of this commentary are to review the updated recommendations within the context of community-based lifestyle intervention programs such as those currently being offered throughout the United States for the primary purpose of diabetes prevention and to discuss the implications for those providers developing and implementing such programs.
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