Search

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Objective To separately compare the long-term risk of mortality among bariatric surgical patients undergoing either RYGB or SG to large, matched, population-based cohorts of patients with severe obesity who did not undergo surgery. Background Bariatric surgery has been associated with reduced long-term mortality compared to usual care for severe obesity which is particularly relevant in the COVID-19 era. Most prior studies involved the Roux-en-Y gastric bypass (RYGB) operation and there is less long-term data on the sleeve gastrectomy (SG). Methods In this retrospective, matched cohort study, patients with a body mass index ≥35 kg/m2 who underwent bariatric surgery from January 2005 to September 2015 in three integrated health systems in the United States were matched to nonsurgical patients on site, age, sex, body mass index, diabetes status, insulin use, race/ethnicity, combined Charlson/Elixhauser comorbidity score, and prior health care utilization, with follow-up through September 2015. Each procedure (RYGB, SG) was compared to its own control group and the two surgical procedures were not directly compared to each other. Multivariable-adjusted Cox regression analysis investigated time to all-cause mortality (primary outcome) comparing each of the bariatric procedures to usual care. Secondary outcomes separately examined the incidence of cardiovascular-related death, cancer related-death, and diabetes related-death. Results Among 13,900 SG, 17,258 RYGB, and 87,965 nonsurgical patients, the 5-year follow-up rate was 70.9%, 72.0%, and 64.5%, respectively. RYGB and SG were each associated with a significantly lower risk of all-cause mortality compared to nonsurgical patients at 5-years of follow-up (RYGB: HR = 0.43; 95% CI: 0.35,0.54; SG: HR = 0.28; 95% CI: 0.13,0.57) Similarly, RYGB was associated with a significantly lower 5-year risk of cardiovascular- (HR = 0.27; 95% CI: 0.20, 0.37), cancer- (HR = 0.54; 95% CI: 0.39, 0.76), and diabetes-related mortality (HR = 0.23; 95% CI:0.15, 0.36). There was not enough follow-up time to assess 5-year cause-specific mortality in SG patients, but at 3-years follow up, there was significantly lower risk of cardiovascular- (HR = 0.33; 95% CI:0.19, 0.58), cancer- (HR = 0.26; 95% CI:0.11, 0.59), and diabetes-related (HR = 0.15; 95% CI:0.04, 0.53) mortality for SG patients. Conclusion This study confirms and extends prior findings of an association with better survival following bariatric surgery in RYGB patients compared to controls and separately demonstrates that the SG operation also appears to be associated with lower mortality compared to matched control patients with severe obesity that received usual care. These results help to inform the trade-offs between long-term benefits and risks of bariatric surgery.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

According to Stark, the motive of God’s glory provided the ideological basis for the Scientific Revolution. Smith argues that by the time that revolution began to spread to the human sciences in the late 1800’s and early 1900’s, another revolution was emerging, with which the human sciences have become thoroughly confounded, the Secular Revolution. Following MacIntyre, Johnson suggests that this confounding has created a crisis for the Christian intellectual and soul-care traditions, but one that was largely self-inflicted. One of the consequences of this crisis has been a serious wound/division in the Christian body regarding the relation between the Bible, and its theocentric worldview and way of life, and the current form of psychology and the therapeutic sciences (psychiatry, psychotherapy, and counseling). In this article, reasons are given for imagining one way the glory of God could again become a supreme motive among Christians in Western science, specifically psychology and the therapeutic sciences, that would help to overcome the current biblical knowledge/empirical knowledge dichotomy that afflicts the Christian community in these fields and could unify and empower it to develop Christian alternatives to their mainstream versions.

OBJECTIVE: A retrospective cohort study investigated the association between having surgery and risk of mortality for up to five years and if this association was modified by incident End Stage Renal Disease (ESRD) during the follow-up period. SUMMARY BACKGROUND DATA: Mortality risk in individuals with pre-dialysis chronic kidney disease (CKD) is high and few effective treatment options are available. Whether bariatric surgery can improve survival in people with CKD is unclear. METHODS: Patients with class II and III obesity and pre-dialysis CKD stages 3 – 5 who underwent bariatric surgery between 1/1/2006 and 9/30/2015 (n = 802) were matched to patients who did not have surgery (n = 4,933). Mortality was obtained from state death records and ESRD was identified through state-based or healthcare system-based registries. Cox regression models were used to investigate the association between bariatric surgery and risk of mortality and if this was moderated by incident ESRD during the follow-up period. RESULTS: Patients were primarily women (79%), non-Hispanic White (72%), under 65 years old (64%), who had a BMI ≥ 40 kg/m(2) (59%), diabetes (67%) and hypertension (89%). After adjusting for incident ESRD, bariatric surgery was associated with a 79% lower 5-year risk of mortality compared to matched controls (HR = 0.21; 95% CI: 0.14-0.32; p < .001). Incident ESRD did not moderate the observed association between surgery and mortality (HR = 1.59; 95% CI 0.31-8.23; p = .58). CONCLUSIONS: Bariatric surgery is associated with a reduction in mortality in pre-dialysis patients regardless of developing ESRD. These findings are significant because patients with CKD are at relatively high risk for death with few efficacious interventions available to improve survival.

The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

This article focuses on the challenges to and rewards of using technology in diabetes care. The authors provide everyday, practical information regarding the integration of technology, including insulin pumps, continuous glucose monitoring devices, and other diabetes consumer technologies, into busy primary care practices. Cases are presented to highlight these tips.

Background and Objectives: The goal of this study was to investigate the impact of medical students functioning in the role of scribe on students’ learning, medical practice, and preceptor. Methods: Third-year students from the University of North Dakota School of Medicine and Health Sciences volunteered and were trained to function in the role of scribe. Preceptors also completed training to have students scribe in their practice. The students, preceptors, and staff completed questionnaires assessing perceptions of the impact on the student, the practice, and the provider. We elicited comments and concerns from students, staff, and preceptors. Results: All groups perceived medical students’ scribing as helpful for teaching medical students in the clinical setting, with an average questionnaire score for all groups of 4.7/5. The students reported it was a positive experience. It allowed them to be more engaged, improved the learning environment, and didn’t detract from clinical learning. Staff reported that students were more engaged, and scribing did not impact time management. Preceptors reported that students were more engaged in the practice, and with their team. Preceptors reported it was also easier to teach, and easier to stay on time with medical students scribing. All reported that documentation was important to learn in the third year of medical school, and that students should be trained to function in a limited scribe role. Conclusions: Allowing students to document in the electronic medical record provides many benefits to students and preceptor practices and should be encouraged and advocated for in medical education.

Phenomenon: Chronic disease is a leading cause of death and disability in the United States. With an increase in the demand for healthcare and rising costs related to chronic care, physicians need to be better trained to address chronic disease at various stages of illness in a collaborative and cost-effective manner. Specific and measurable learning objectives are key to the design and evaluation of effective training, but there has been no consensus on chronic disease learning objectives appropriate to medical student education. Approach: Wagner's Chronic Care Model (CCM) was selected as a theoretical framework to guide development of an enhanced chronic disease prevention and management (CDPM) curriculum. Findings of a literature review of CDPM competencies, objectives, and topical statements were mapped to each of the six domains of the CCM to understand the breadth of existing learning topics within each domain. At an in-person meeting, medical educators prepared a survey for the modified Delphi approach. Attendees identified 51 possible learning objectives from the literature review mapping, rephrased the CCM domains as competencies, constructed possible CDPM learning objectives for each competency with the goal of reaching multi-institutional consensus on a limited number of CDPM learning objectives that would be feasible for institutions to use to guide enhancement of medical student curricula related to CDPM. After the meeting, the group developed a survey which included 39 learning objectives. In the study phase of the modified Delphi approach, 32 physician CDPM experts and educators completed an online survey to prioritize the top 20 objectives. The next step occurred at a CDPM interest group in-person meeting with the goal of identifying the top 10 objectives. Findings: The CCM domains were reframed as the following competencies for medical student education: patient self-care management, decision support, clinical information systems, community resources, delivery systems and teams, and health system practice and improvement. Eleven CDPM learning objectives were identified within the six competencies that were most important in developing curriculum for medical students. Insights: These learning objectives cut across education on the prevention and management of individual chronic diseases and frame chronic disease care as requiring the health system science competencies identified in the CCM. They are intended to be used in combination with traditional disease-specific pathophysiology and treatment objectives. Additional efforts are needed to identify specific curricular strategies and assessment tools for each learning objective.

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2014.

Objective: To evaluate the clinical outcomes of lyopreserved placental membrane containing viable cells (vLPM) in the treatment of nonhealing wounds of various etiologies, and to compare them to those previously reported for cryopreserved placental membrane containing viable cells (vCPM). Approach: Patients with nonhealing wounds who qualified to receive advanced wound therapies were consecutively enrolled and treated weekly with vLPM plus standard of care (SOC) at five centers. Data were de-identified and retrospectively analyzed. Outcomes included closure, time to closure, number of vLPM applications, and adverse events (AEs). Results: Seventy-eight patients with 98 wounds (41 diabetic foot ulcers [DFUs], 19 venous leg ulcers [VLUs], 10 surgical, and 28 others) with an average size of 13.3 cm2 and 8.7 months duration were treated. Fifty-eight of the 98 wounds (59.2%) achieved complete closure with median time to closure of 63 days and 6 vLPM applications. The closure by wound etiology was 63% for DFUs, 47% for VLUs, 70% for surgical wounds, and 57% for other types of wounds. Similar closure rates have been previously demonstrated for vCPM. Wound duration was the main predictor of closure: 65.8% versus 30.0% (p = 0.004) closure was achieved for wounds of ≤12 and >12 months duration, respectively. There were no AEs related to vLPM application. Innovation: This is the first multicenter case series evaluating the clinical outcomes of vLPM in a real-world setting. Conclusion: These results support clinical equivalency between the two placental membrane formulations with the added convenience of room-temperature storage for vLPM, allowing it to be used in any wound-care setting.

Higher closure rates for chronic diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs) have been reported for placental products adjunct to standard of care (SOC) vs SOC alone; however, data for other types of wounds are limited.This study aimed to evaluate the clinical outcomes of amnion-derived and chorion-derived cryopreserved placental membranes containing viable cells (vCPM) in the treatment of nonhealing upper-extremity and lower-extremity wounds of nondiabetic and nonvenous pathophysiology. The authors hypothesized that treatment with vCPM adjunct to SOC would result in positive clinical outcomes for these wounds.Data for all patients consecutively treated between January 2016 and May 2019 with vCPM adjunct to SOC were retrospectively collected and analyzed through chart review at a single center. Patients with wounds of diabetic and venous pathophysiology and patients receiving other skin substitutes during the course of vCPM treatment were excluded from the study. Outcomes included wound closure, time to closure, number of applications, and vCPM-related adverse events (AEs).Ninety-two patients with 104 wounds received vCPM applications adjunct to SOC. The median wound size was 3.15 cm2 (mean, 12.7 cm2) with a median duration of 1.5 months (mean, 3.9 months). Eighty-seven of the 104 wounds (83.7%) achieved complete wound closure in a median time of 41 days and 3 applications of vCPM. There were no differences in closure rates between upper-extremity and lower-extremity wounds, nor between the amnion and chorion products. There were no vCPM-related adverse events.This study provides valuable information to physicians, hospitals, and payers as it pertains to medically necessary and appropriate patient treatment.

PURPOSE This study gathers validity evidence of an expanded History and Physical examination (H&P 360) to address chronic diseases through incorporation of biopsychosocial elements that are lacking in traditional H&P assessments via a multisite randomized controlled trial among medical students. METHOD Third- and fourth-year medical students (n = 159) at 4 schools participated in an Objective Structured Clinical Examination designed with 2 cases for chronic disease. Students were randomized into the treatment group, which involved brief written instructions on how to use the H&P 360 followed by a standardized patient (SP) interaction, or the control group, which used the traditional H&P in an SP interaction without additional instructions. Validity evidence was gathered for content (alignment with an empirically derived expanded history list), response process (feedback from raters and learners on the process), internal structure (reliability and item-level psychometrics), relations to other variables (comparison between treatment and control groups), and consequences (survey results from learners on experience). RESULTS H&P 360 items were blueprinted by faculty experts. SP observation checklist grading was consistent, and postassessment debrief confirmed favorable educational experience among learners. The reliability of the H&P 360 was .76. Overall mean scores on the H&P 360 content (mean = 15.96, standard deviation [SD] = 3.66) were significantly higher compared with the traditional H&P (mean = 10.99, SD = 2.69, Cohen's d = 1.17, P < .001). CONCLUSIONS Medical students using the H&P 360 collected significantly more biopsychosocial information compared with students using the traditional H&P, providing empirical support for teaching and assessing biopsychosocial information. The assessment demonstrated strong validity evidence supporting the use of the H&P 360 assessment in medical schools.

The progressive nature of type 2 diabetes (T2D) means that many patients will require basal insulin therapy at some point in the course of the disease due to β-cell failure. As basal insulin primarily targets fasting plasma glucose, patients may still experience considerable postprandial glucose excursions and therefore require an additional agent to achieve good glycemic control. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) provide an alternative to prandial insulin, with the benefits of fewer daily injections, and a lower risk of hypoglycemia and weight gain. Two fixed-ratio combinations (FRCs) of basal insulin and a GLP-1 RA are now available in the USA and the EU: insulin glargine + lixisenatide (iGlarLixi) and insulin degludec + liraglutide (IDegLira). Titratable FRCs are suitable for most patients with T2D and can help to simplify treatment regimens into one daily injection, potentially aiding in patient adherence. The complementary modes of action of the two components target seven of the many known pathophysiologic defects in T2D. FRCs have demonstrated enhanced glycemic control compared with their constituent components alone, comparable risk of hypoglycemia compared with basal insulin alone, and better tolerability compared with the GLP-1RA component alone due to the slower titration. In this article, we discuss the advantages of FRCs over multiple daily injections, present case studies of typical patients who could benefit from FRC therapy, and outline practical considerations for the initiation of FRC therapy in clinical practice. Funding Sanofi.

Reconstruction of the nasal tip is challenging due to the highly contoured topography and the limited nearby tissue reservoirs. Nasal reconstruction requires complex multi‐staged surgical procedures with replacement of damaged structures by the autologous full‐thickness flaps or split‐thickness skin grafts.1 Reestablishing the tissue triangle is difficult due to poor blood supply and the potential for large scars.1, 2 Depending on the procedure, some full‐thickness nose flaps are performed in two stages involved a transfer with possible debulking and/or a potential for surgical revision 6‐12 months later, once the repaired tissue at the surgical site has been matured.3, 4 Partial or split‐thickness skin grafts are a less favorable option as differences in tissue thickness and pigmentation or secondary contraction of meshed grafts may result in poor esthetic appearance.5 Alternative treatment for poor surgical candidates, patients unwilling to undergo staged surgical reconstruction of the face, or cases in which autologous nasal grafts have already failed is usually limited to wound closure by secondary intention.5, 6 However, the full‐thickness nasal tip defects do not heal well under second intention resulting in visible large scars prone to postoperative scar depression. Here authors present a nonsurgical alternative approach for closure of a large full‐thickness nasal tip wound using a viable cryopreserved placental membrane (vCPM), a commercially available tissue allograft. This case describes a young female patient with significant facial disfigurement secondary to a large nonmalignant necrotic lesion that destroyed the dermal and subcutaneous soft tissues of the nasal tip, leaving osseocartilaginous structures exposed. The patient was referred to a plastic surgeon to do a nasal tip reconstruction, but she was unwilling to undergo a staged surgical procedure and instead selected to receive outpatient applications of a viable cryopreserved placental membrane. Augmentation of wound closure by secondary intention with two applications of vCPM resulted in re‐establishment of the nasal tip with normal esthetic contour.

The American Diabetes Association (ADA) annually updates its Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes.For the 2018 standards, the ADA Professional Practice Committee searched MEDLINE through November 2017 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C depending on the quality of evidence or E for expert consensus or clinical experience. The standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions.This synopsis focuses on guidance relating to cardiovascular disease and risk management in nonpregnant adults with diabetes. Recommendations address diagnosis and treatment of cardiovascular risk factors (hypertension and dyslipidemia), aspirin use, screening for and treatment of coronary heart disease, and lifestyle interventions.

The alarming rise in the number of people living with type 2 diabetes (T2D) presents primary care physicians with increasing challenges associated with long-term chronic disease care. Studies have shown that the majority of patients are not achieving or maintaining glycemic goals, putting them at risk of a wide range of diabetes-related complications. Disease- and self-management programs have been shown to help patients improve their glycemic control, and are likely to be of particular benefit for patients with diabetes dealing with these issues. Anticipatory guidance is an individualized, proactive approach to patient education and counseling by a health-care professional to support patients in better coping with problems before they arise. It has been shown to improve disease outcomes in a variety of chronic conditions, including diabetes. While important at all stages, anticipatory guidance may be of particular importance during changes in treatment regimens, and especially during transition to, and escalation of, insulin-based regimens. The aim of this article is to provide advice to physicians on anticipatory guidance for basal-insulin dosing, focusing on appropriate basal-insulin-dose increase and prevention of potentially deleterious basal-insulin doses, so called overbasalization. It also provides an overview of new treatment options for patients with T2D who are not well controlled on basal-insulin therapy, fixed-ratio combinations of basal insulin and glucagon-like peptide-1 receptor agonists, and advice on the type of anticipatory guidance needed to ensure safe and appropriate switching to these therapies.

Creation of educational experiences to promote interprofessional education (IPE) and collaborative practice team skills can be resource-intensive and beyond the capacity of many institutions. Implementation of developed IPE curricular elements to other institutions is a promising means of expanding access to IPE. This paper describes the process of implementing an IPE error disclosure experience used at one academic health center to three additional centers during 2012–2013. Participating institutions found that implementing an existing IPE curricular experience to their institutional sites required minimal resource investment in case development, allowing them to focus their efforts on implementation and evaluation. Student and faculty feedback were positive and participating institutions continue to use the activity as part of their IPE offerings.

The American Diabetes Association (ADA) updates its Standards of Medical Care (SOMC) in Diabetes annually. These ADA standards make up a comprehensive document that serves as an excellent resource for clinical care. The current article comes from the ADA's Primary Care Advisory Group. This article highlights key aspects of the SOMC that are relevant to the day-to-day practice of osteopathic primary care physicians. It is not intended to replace the full SOMC but will refer to the master document for further explanation and evidence-based support.

Background and objective. Connections between oral health and systemic disease, specifically diabetes, are well described in the literature. Screening strategies for diabetes in dental settings and dental screenings in diabetes care settings exist. The purpose of this study was to evaluate the communication and referral patterns between dentists and physicians in a rural state with respect to recognition of dental disease and diabetes. Methods. Surveys were sent to the members of the North Dakota Academy of Family Physicians, the North Dakota Medical Association, and the North Dakota Dental Association. Results. Overall, 85 responses were collected, with 100% of responding physicians and dentists answering “yes” to a perceived link between oral and systemic health. Physician respondents tended to make a referral for dental evaluation in patients with prediabetes or diabetes more often than dentists referred patients with periodontal disease to physicians. Conclusion. Awareness of the link between dental disease and diabetes and of the need for referral is higher among physicians than among dentists. Opportunity exists to improve awareness and increase referrals.

Background Smoking exacerbates the complications of diabetes, but little is known about whether patients with diabetes have more unplanned medical visits. This study examines the association between smoking status and unplanned medical visits among patients with diabetes. Methods Data were drawn from electronic medical records (EMR’s) from a large healthcare provider in the Northern Plains region of the US, from adult (≥18 years old) patients with type 1 or type 2 diabetes who received care within this healthcare system at least once during the 3-year period spanning 2014-16 (N=62,149). The association between smoking status (current, former, or never smoker) and having ≥1 unplanned visit (comprised of emergency department visits, hospitalizations, hospital observations, and urgent care) was examined after adjusting for age, race/ethnicity, and body mass index (BMI). The top ten most common diagnoses for unplanned visits were examined by smoking status. Results Both current and former smoking were associated with an approximately 1.2-fold increase in the odds of having at least one unplanned medical visit in the 3-year period (OR=1.22, 95% CI=1.16-129; OR=1.23, 95% CI=1.19-1.28, respectively), relative to never-smokers. Most common diagnoses for all patients were pain-related. However, diagnoses related to musculoskeletal system and connective tissue disorders were more common among smokers. Smoking is associated with a higher rate of unplanned medical visits among patients with diabetes in this regional healthcare system. Conclusions Results from this study reveal higher rates of unplanned visits among smokers and former smokers, as well as increased frequencies of unplanned medical visits among current smokers.