Health Care Provider Prescribing Habits and Barriers to Use of New Type 2 Diabetes Medications: A Single-System Survey Study.

This survey study evaluated type 2 diabetes medication prescribing patterns of health care providers in different specialties and of different professional designations or levels of training at an academic health care system and sought to identify factors influencing medication choices and uncover barriers to prescribing glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors. High cost and the need for prior authorizations were reported as the main barriers to prescribing drugs in these two classes, along with a lack of experience among some specialists. Greater system support to decrease the administrative burden of prescribing newer medications and greater dialogue among the specialties caring for patients with cardiorenal comorbidities can improve prescribing of these drugs in accordance with clinical practice recommendations.

Association of Patient Characteristics, Diabetes, BMI, and Obesity With Severe COVID-19 in Metropolitan Detroit, MI.

Identification of specific risk factors for severe coronavirus disease 2019 (COVID-19) is crucial for prevention of poor outcomes and mortality. This retrospective cohort study of patients hospitalized with COVID-19 demonstrated that older age, male sex, Black race, diabetes, elevated BMI, and elevated inflammatory markers were correlated with critical illness in COVID-19. Older age, male sex, diabetes, and inflammatory markers, but not elevated BMI, were associated with mortality. Despite having greater odds of critical illness, Black patients had lower odds of death than White patients. Older age, male sex, diabetes, and elevated inflammatory markers were significantly associated with venous thromboembolism. These findings suggest a need to aggressively identify and manage modifiable risk factors (i.e., diabetes and elevated BMI) and encourage vaccination of at-risk individuals to prevent poor outcomes from COVID-19.

PATIENT PERSPECTIVES ON OBESITY MANAGEMENT: NEED FOR GREATER DISCUSSION OF BMI AND WEIGHT-LOSS OPTIONS BEYOND DIET AND EXERCISE, ESPECIALLY IN PATIENTS WITH DIABETES.

Objective: To identify perceptions of obesity management in patients with and without diabetes. Methods: A 48-question survey was administered in 2018 to our Endocrinology Clinic's adult patients with a body mass index (BMI) ≥30 kg/m2. Chi-squared or Fisher's exact tests were used to compare variables between groups. Results: Of 146 respondents, 105 had diabetes and 41 did not. Most respondents were female (61.4%), African American (66.4%), and with an income <$50,000 (58.6%). Those with diabetes had significantly greater comorbidities of hypertension, high cholesterol, and arthritis. Over 90% in both groups agreed that obesity is related to hypertension, diabetes, heart disease, and early death. Only 48% were aware of their BMI, and only 30.5% with diabetes and 41.5% without diabetes perceived themselves to be obese. Over 60% in each group reported discussion of diet and exercise with their providers, whereas few in both groups reported referral to a formal weight-loss program (18.9%) or to a specialty that manages obesity (4.2%), or discussion of anti-obesity medications (11.2%) or bariatric surgery (8.4%). Reported concerns with anti-obesity medications and bariatric surgery included lack of knowledge and side effects or complications. Conclusion: These findings revealed excellent patient awareness of obesity as a health problem but misperception of obese status and unawareness of BMI. Presence of diabetes and other comorbidities did not result in greater discussion of weight-loss methods beyond diet and exercise. Increased patient education and discussion of specific weight-loss services, anti-obesity medications, and bariatric surgery are needed. Abbreviations: BMI = body mass index; DM = diabetes mellitus; HbA1c = hemoglobin A1c; HCP = healthcare provider.

PROVIDER PRACTICE HABITS AND BARRIERS TO CARE IN OBESITY MANAGEMENT IN A LARGE MULTICENTER HEALTH SYSTEM.

OBJECTIVE: To identify provider recommendations and barriers in obesity management in a multicenter academic health system with extensive weight-loss management resources. METHODS: A 26-question online survey was sent to attending physicians, trainees, and advanced practice providers in primary care specialties (internal medicine, family medicine, women's health) and endocrinology. RESULTS: The survey response rate was 26% (111/430). Of respondents, 50% were internal medicine, 24% family medicine, 16% women's health, and 9% endocrinology. The majority were attending physicians (54%) and residents (40%). About 50% of respondents advised weight loss for a body mass index (BMI) >30 kg/m2 in >50% of clinic visits. Limited time (82%) was the most common reason for not discussing weight loss, followed by the perception that discussion would not change patient behavior, insufficient knowledge, and discomfort broaching the subject. Common barriers to prescribing anti-obesity medications included limited experience (57%) and concern for adverse reactions (26%). Only 44% offered bariatric surgery to >50% of their patients who met criteria. Primary reasons for not referring included concerns of high surgical risk from comorbidities (57%) and potential adverse events (32%). Endocrinology had the highest referral to surgery. Attending physicians and fellows were more likely than residents to advise weight loss at lower BMI, offer medications, and refer to bariatric surgery. CONCLUSION: Our study reveals reluctance and lack of primary care confidence in managing obesity with pharmacotherapy and bariatric surgery, especially in the earlier stages of obesity. Barriers to care include lack of clinic time, limited experience, and concerns about treatment risks. ABBREVIATIONS: BMI = body mass index; HbA1c = hemoglobin A1c; IRB = Institutional Review Board.

INCIDENTAL THYROID NODULES: RACE/ETHNICITY DISPARITIES AND OUTCOMES.

OBJECTIVE: Black patients have a significantly lower incidence of well-differentiated thyroid cancer (WDTC) compared to all other race/ethnic groups, while white patients appear to be at greater risk. This study examines incidental thyroid nodules (ITNs) to assess whether racial disparities in WDTC arise from a differential discovery of ITNs-perhaps due to socioeconomic disparities-or reflect true differences in thyroid cancer rates. METHODS: A retrospective review was performed of all patients who underwent fine-needle aspiration (FNA) of thyroid nodules by our academic medical center's endocrinology division between January 2006 and December 2010. Medical records were reviewed to identify whether the biopsied thyroid nodule was discovered incidentally through nonthyroid-related imaging or identified by palpation. RESULTS: FNAs were performed on 1,369 total thyroid nodules in 1,141 study patients; 547 (48%) were classified as white, and 593 (52%) were classified as nonwhite. Among this cohort, 36.6% of patients underwent biopsy for an ITN. White patients were 1.6 times more likely to have undergone a biopsy for a nodule that was incidentally identified compared to nonwhites ( P<.0001). Indicators of socioeconomic status (SES) did not have a significant association with ITNs. Within the ITN cohort, 4.9% of nonwhite patients were found to have a thyroid malignancy compared to 12.9% of white patients ( P<.01). CONCLUSION: The higher incidence of thyroid cancer in white patients appears to be not only due to diagnostic bias, but also to a true difference in cancer prevalence. ABBREVIATIONS: FNA = fine-needle aspiration; ITN = incidental thyroid nodule; SEER = Surveillance Epidemiology and End Results; SES = socioeconomic status; WDTC = well-differentiated thyroid cancer.

Personalizing Type 2 Diabetes Management: Use of a Patient-Centered Approach to Individualizing A1C Goals and Pharmacological Regimens.

IN BRIEF Caring for people with type 2 diabetes requires a patient-centered approach to treatment targets and medication regimens. Focusing on patients' individual characteristics, needs, and treatment responses can improve compliance and clinical outcomes. Medication selection can be guided by the mechanisms of action, advantages, disadvantages, and costs of available options; patients' behavioral and psychological variables, personal preferences, and socioeconomic status also should be taken into account. This article provides an overview of patient-centered and individualized diabetes management, offers pharmacological recommendations for specific clinical scenarios, and describes a complicated case illustrating the patient-centered approach in clinical practice.

Graves Disease Following Subacute Thyroiditis in a Chinese Man.

Background/Objective: The development of Graves disease (GD) after subacute thyroiditis (SAT) is rare, with approximately 31 reported cases, of which only 5 occurred in men. We describe a case of GD diagnosed based on newly elevated thyroid-stimulating immunoglobulin (TSI) and thyroid-stimulating hormone (TSH) receptor autoantibody (TRAb) levels after SAT. Case Report: A 32-year-old Chinese man presented with right anterior neck pain, swelling, sore throat, cough, and fever. He had a diffuse tender goiter but no proptosis, lid lag, or stare. His TSH level was 0.03 mIU/mL (normal range [NR] 0.45-5.33 mIU/mL), serum free thyroxine (FT4) level was 2.40 ng/dL (NR 0.61-1.44 ng/dL), total triiodothyronine (TT3) level was 113 ng/dL (NR 87-178 ng/dL), TSI level was <0.10 IU/L (NR < 0.10 IU/L), and erythrocyte sedimentation rate was 21 mm/h (NR < 15 mm/h). After 7 weeks of prednisone, the symptoms resolved, FT4 level was 0.95 ng/dL, and TT3 level was 91 ng/dL. At 11 weeks after SAT onset, the TSH level was <0.01 mIU/mL, TT3 level was 257 ng/dL, FT4 level was 3.03 ng/dL, TSI level was 1.94 IU/L, then 3.42 IU/L 2 weeks later, TRAb level was 8.72 IU/L (NR < 2 IU/L), and erythrocyte sedimentation rate was 4 mm/h. After 1 month of methimazole, the FT4 level was 1.32 ng/dL and TT3 level was 110 ng/dL. Genetic testing revealed human leukocyte antigen-B35 and DRB1∗15:01 positivity. Discussion: GD after SAT is thought to be due to the activation of thyroid autoimmunity induced by SAT in genetically susceptible individuals. Conclusions: This case illustrates the induction of thyroid autoimmunity after SAT, resulting in GD, supporting TSI and/or TRAb testing if hyperthyroidism recurs. The presence of HLA alleles associated with SAT and GD suggests a genetic contribution to the development of thyroid autoimmunity.

Pheochromocytoma-Induced Takotsubo Cardiomyopathy.

Pheochromocytoma, a rare catecholamine-secreting tumor, typically manifests itself with paroxysmal hypertension, tachycardia, headache, and diaphoresis. Less often, symptoms related to substantial hemodynamic compromise and cardiogenic shock occur. We report the case of a 66-year-old woman who presented with abdominal pain. Examination revealed a large right adrenal mass, cardiogenic shock, and severe heart failure in the presence of normal coronary arteries. Within days, the patient's hemodynamic status and left ventricular ejection fraction improved markedly. Results of imaging and biochemical tests confirmed the diagnosis of pheochromocytoma-induced takotsubo cardiomyopathy. Medical therapy and right adrenalectomy resolved the patient's heart failure, and she was asymptomatic postoperatively. We recommend awareness of the link between pheochromocytoma and takotsubo cardiomyopathy, and we discuss relevant diagnostic and management principles.

Bilateral thyroid hematomas after fine-needle aspiration causing acute airway obstruction.

BACKGROUND: Fine-needle aspiration of the thyroid gland is a common procedure that is increasingly being used to evaluate thyroid nodules incidentally found by other imaging means such as computed tomography scans. Rare complications include hematoma, transient vocal cord paralysis, seeding of carcinoma cells, and infection. Of these, hematoma is the most common and is usually small and adequately treated with compression of the site. Only two cases have been previously reported describing large thyroid hematoma after fine-needle aspiration resulting in acute airway compromise and requiring surgical decompression. SUMMARY: We report an interesting case of large bilateral thyroid hematomas after routine fine-needle aspiration causing acute airway obstruction in a patient with hypertension and end stage renal disease taking aspirin.

Comparison of incidental versus palpable thyroid nodules presenting for fine-needle aspiration biopsy.

BACKGROUND: Many attribute the rise in incidence of thyroid cancer to a deluge of radiologically identified incidental thyroid nodules. The clinical implications are unclear. METHODS: A review was performed of all patients who underwent fine-needle aspirations of thyroid nodules by our academic medical center's Endocrinology Division between 2006 and 2010. Medical records were reviewed to identify whether the thyroid nodule was discovered incidentally or by palpation. RESULTS: Of 1153 patients, 37.4% underwent a biopsy because of an incidental thyroid nodule. These patients were significantly more likely to be >45 years old, men, white race, and with a body mass index >30 kg/m2 . Of the 17.2% of incidentalomas that led to surgery, 8.5% were found to be thyroid cancer. CONCLUSION: Thyroid nodules discovered incidentally are increasing the diagnosis of subclinical thyroid cancers. Not investigated previously, our study found that the mode of detection was not related to malignancy or surgery.