1. Overweight and obesity prevalent and poorly managed among adults with type 1 diabetes
Only 50% of patients with type 1 diabetes receive lifestyle advice from providers or engage in modified behaviors
Abstract: https://www.acpjournals.org/doi/10.7326/M22-3078
URL goes live when the embargo lifts
A brief research report found adults with type 1 diabetes had overweight or obesity at the same rates as adults without diabetes, but only half of these patients received lifestyle recommendations from providers or engaged in lifestyle modification for weight management. The report is published in Annals of Internal Medicine.
Survival has significantly improved in patients with type 1 diabetes over the past 2 decades, shifting the health profile of this population. Obesity, once rare among persons with type 1 diabetes, now affects up to 37 percent of U.S. adults with type 1 diabetes. However, current studies are based on selected populations and have not considered engagement in lifestyle modification.
Researchers from Johns Hopkins Bloomberg School of Public Health conducted an analysis of data from 128,571 nonpregnant adults included in the National Health Interview Survey. They report that between 2016 and 2021, 64 percent of adults without diabetes had overweight or obesity, compared with 62 percent of adults with type 1 diabetes and 86 percent with type 2 diabetes. The authors also found that adults with overweight or obesity and type 1 diabetes received lifestyle recommendations more frequently than those without diabetes but less frequently than those with type 2 diabetes. They also found that persons with type 1 diabetes were the least likely of those groups to report increased physical activity or reduced caloric intake to manage overweight or obesity. According to the authors, the development of more comprehensive clinical guidelines, with an emphasis on individualized patient education, may improve weight management in these patients.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org . To speak with the corresponding author Michael Fang, PhD, MPH, please email Jonathan Eichberger at je@jhu.edu .
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2. Summary of VA/DoD guidelines for management of chronic pain provides new recommendations on opioid use and mental health evaluations
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2917
Editorial: https://www.acpjournals.org/doi/10.7326/M23-0229
URL goes live when the embargo lifts
In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. These updated guidelines include recommendations about the use of buprenorphine instead of full agonist opioids during chronic pain management. A summary of key recommendations and a related review of published evidence are published in Annals of Internal Medicine.
Chronic pain is common and affects quality of life. Opioid medications have been used for the treatment of pain but can have serious harms from overdose and substance use disorder. Thus, physicians need to be careful about reducing the risk and exposure to prescription opioids while still caring for their patients with chronic pain. The authors summarize the recommendations that have the most clinical impact, including recommendations about the use of buprenorphine, assessing patients for behavioral health conditions, and education related to pain and opioids.
The amount of research on long- and short-term opioid use for pain conditions has grown substantially since the previous recommendations issued in 2017. This updated guideline has important new recommendations for behavioral health assessment in all patients; a recommendation for preoperative opioid and pain management education; and a recommendation to use buprenorphine instead of a full agonist opioid for patients who are receiving daily opioids for chronic pain.
Researchers from ECRI conducted a systematic evidence review that the guideline panel used to develop recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. The guideline group newly recommends the use of buprenorphine instead of full agonist opioid because of a lower risk for overdose and misuse. They recommend screening for additional mental health conditions that potentially increase risk in patients with chronic pain when considering long-term opioid therapy. They additionally recommend assessing for behavioral health conditions, history of traumatic brain injury, and psychological factors because these conditions are associated with higher risk for harm. The guideline group also recommends screening for pain catastrophizing and co-occurring behavioral health conditions to identify those at higher risk for negative outcomes when opioids are being considered in patients with acute pain. Finally, the group recommends providing patients with preoperative opioid and pain management education to reduce the risk for prolonged opioid use for postsurgical pain.
An accompanying editorial by authors from the Albert Einstein College of Medicine highlight that the quality of available evidence for the buprenorphine recommendation is low, and the recommendation lacks clarity in terms of formulation, dosing, and frequency of dosing, along with an unclear target population. They add that the buprenorphine recommendation seems to conflict with other recommendations, including caution against prescribing long-acting opioids in opioid-naive patients. The authors add that, although the field of pain medicine is likely to embrace this new buprenorphine recommendation, more clearly specifying how it should be implemented—and improving and expanding buprenorphine research, along with OUD and buprenorphine education and training—will likely improve the lives of persons with chronic pain.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org . To speak with the author of the synopsis, James Sall, PhD, please email James.Sall@va.gov . To speak with someone from ECRI, please contact Laurie Menyo at lmenyo@ecri.org .
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3. Critical care specialists debate best management strategy for sepsis and septic shock
‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center
Abstract: https://www.acpjournals.org/doi/10.7326/M22-3385
URL goes live when the embargo lifts
In a new Annals ‘Beyond the Guideline’s feature, two critical care specialists discuss and debate conditional guideline recommendations on using lactate to guide resuscitation, the use of balanced crystalloids versus normal saline, and the use of corticosteroids for management of sepsis and septic shock. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.
Sepsis is a potentially life-threatening systemic dysregulatory response to infection, and septic shock occurs when sepsis leads to systemic vasodilatation and subsequent tissue hypoperfusion. In 2021, the Surviving Sepsis Campaign published updated guidelines on the management of sepsis and septic shock. Although these guidelines provide a useful review of key recommendations and evidence, some issues remain incompletely resolved.
BIDMC Grand Round discussants Drs. Katherine Berg and Taison Bell recently debated several weak recommendations from the 2021 Surviving Sepsis Campaign guidelines with regards the case of Ms. S., a 70-year-old woman with septic shock.
In their assessments, Dr. Berg finds lactate level to be a quick, inexpensive, and useful indirect measurement to assess illness severity and guide resuscitation. Dr. Bell prefers to rely on dynamic assessments of intravascular volume status to guide fluid resuscitation. Dr. Berg favors balanced crystalloids (BCs) for resuscitation, especially for patients with acute kidney injury (AKI), such as Ms. S. Dr. Bell believes the debate over fluid choice is less important than otherwise perceived both because of the general trend toward less fluid resuscitation in critical illness and because of the inconsistent results in trials comparing BCs to normal saline. Dr. Berg does not routinely employ corticosteroids in the first 24 hours in patients in whom shock is stable or improving, but when necessary prefers a regimen of hydrocortisone plus fludrocortisone given the strongest data associated with this combination. Dr. Bell finds corticosteroids to be beneficial due to the improvement in important outcomes like time receiving vasopressors, duration of mechanical ventilation, and ICU length-of-stay.
A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds .
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org . For an interview with the discussants, please contact Kendra McKinnon at Kmckinn1@bidmc.harvard.edu .
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Also new in this issue:
Forgiving Physician Debt
Justin A. Grischkan, MD; and David A. Asch, MD
Ideas and Opinions
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2832
Indigenous Peoples’ Limited Access to Reproductive Care
Amanda Collar, PhD
Ideas and Opinions
Abstract: https://www.acpjournals.org/doi/10.7326/M22-3481
Annals of Internal Medicine
Data/statistical analysis
People
Prevalence and Management of Obesity in U.S. Adults With Type 1 Diabetes
14-Feb-2023