Faculty Bibliography

BACKGROUND:Diabetic peripheral neuropathy (DPN) is a serious complication of type 2 diabetes (T2DM). Guidelines recommend targeting modifiable risk factors for primary prevention, but their effectiveness is unclear. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of interventions targeting modifiable risk factors to prevent DPN in adults with T2D. METHODS:We searched PubMed, Embase, and ClinicalTrials.gov databases for RCTs published since 1980 investigating glycemia, lipids, blood pressure (BP), smoking cessation, lifestyle, and multifactorial interventions. Two reviewers independently screened articles; a third reviewer resolved disagreements. Meta-analysis used a random-effects model. Results are reported as odds ratios (ORs) with 95% confidence and prediction intervals. RESULTS:to 23% and narrowed the prediction interval (0.80-1.08). This is clinically explainable: BARI-2D compared insulin-sensitizing versus insulin-providing drug strategies rather than glycemic intensity targets, in patients with coronary artery disease. The four-study analysis showed glycemic control may result in little to no difference in DPN risk (OR 0.93, 95% CI 0.85-1.02). In BARI-2D, an insulin-sensitizing strategy may reduce incident DPN independently of achieved HbA1c (0.84 (95% CI 0.71-0.99)) (low certainty). Single-study evidence suggests that BP-lowering and multifactorial interventions may reduce incident DPN (low certainty). DISCUSSION/CONCLUSIONS:Glycemic intensity interventions may result in little to no difference in incident DPN risk. The BARI-2D drug class-specific finding and single-study evidence suggesting benefit from BP-lowering and multifactorial interventions warrant further rigorous research on incident DPN.

Clinical reasoning is a foundational competency that develops over the course of training and comprises two sub-components. Diagnostic reasoning classifies a patient's condition and assigns a diagnostic label, whereas management reasoning weighs multiple defensible plans with consideration of patient preferences and contextual constraints. Clinical reasoning education has historically emphasized "in-the-head" cognitive processes, such as information gathering, hypothesis generation, problem representation, and differential prioritization, over "out-in-the-world" contextualized processes, such as system navigation, use of tools, and interprofessional management. Generative artificial intelligence (GAI), itself a tool "out-in-the-world," is changing where, with whom and what, and how trainees learn to reason. The unit of reasoning educators must attend to shifts from the individual learner to the learner-AI dyad. This shift creates opportunities for upskilling alongside risks of never-skilling, mis-skilling, and deskilling. Drawing on "in-the-head" information processing theories and "out-in-the-world" situativity theories, the authors propose a redesign of clinical reasoning education. They share learner vignettes to illustrate the upskilling potential and skilling risks most concerning at each stage of training before proposing five cross-cutting strategies for redesign: introduce GAI tools early in the curriculum, preserve reasoning-first GAI-assisted workflows, promote graduated autonomy for GAI use in clinical care, equip faculty to supervise GAI-assisted reasoning, and rethink clinical reasoning assessment. If GAI is integrated deliberately in a theory-informed way, the next generation of learners can be better prepared to incorporate GAI skillfully and responsibly into clinical reasoning.

DESCRIPTION/UNASSIGNED:A work group representing the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) prepared a new VA/DoD clinical practice guideline (CPG) for tobacco use treatment. This article provides a synopsis of the 2026 CPG, which addresses use of commercially available tobacco and nicotine products. METHODS/UNASSIGNED:A multidisciplinary work group developed 19 key questions on clinical topics of highest priority for the VA and DoD populations. Published literature from 1 January 2014 to 10 December 2024 was systematically reviewed using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) framework. Recommendations were made by consensus and informed by evaluation using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method, which assesses quality of evidence and balances benefits and harms, patient preferences, and feasibility. The final document incorporated input from peer review by an external group of experts. RECOMMENDATIONS/UNASSIGNED:The 2026 guideline includes 32 recommendations across 10 topic areas. Key recommendations for increasing abstinence from combustible tobacco include recommending motivational interviewing to increase engagement in treatment of tobacco and nicotine use (strong) and use of U.S. Food and Drug Administration-approved pharmacotherapies (strong), with varenicline recommended over monotherapy with other agents (strong), combination nicotine replacement therapy ([NRT] for example, patch plus lozenge) recommended over NRT monotherapy (single agent) (strong), and extending use of bupropion sustained release beyond 12 weeks (weak). Other key recommendations include varenicline for increasing abstinence from smokeless tobacco (strong) and electronic nicotine delivery systems (weak) and use of NRT or varenicline to increase quit attempts and abstinence in patients not ready to quit in the next 30 days (weak).

BACKGROUND:Prior studies comparing virtual and in-person OSCEs have focused mainly on overall performance scores, with less attention to whether specific communication skills function differently across modalities. OBJECTIVE:To compare the level of communication proficiency required to achieve specific checklist ratings in virtual versus in-person OSCEs. DESIGN/METHODS:We identified Internal Medicine case (IM) OSCE cases conducted in both modalities. In each case, standardized patients (SP) rated resident performance in three communication domains (information gathering, relationship development, and patient education), using a behaviorally anchored scale of "not," "partially," or "well done." We compared overall communication scores and rating distributions across modalities and used a graded response Item Response Theory model to estimate item-level thresholds, representing the communication proficiency needed to move from one rating category to the next. Virtual and in-person threshold estimates were compared using Wald tests. PARTICIPANTS/METHODS:126 PGY-1 IM residents participated across six cases between 2019 and 2023 (in-person = 82, virtual = 54). MAIN MEASURES/METHODS:Mean communication domain scores, rating distributions, and item-level threshold estimates for each checklist item across modalities. KEY RESULTS/RESULTS:Most residents demonstrated sufficient skill to receive "partly" or "well" done ratings on most communication items. Overall communication performance appeared broadly similar across modalities. At the item level, one behavior-"using words patient understood and explaining jargon"-showed a statistically significant difference: residents required a lower level of proficiency to receive a "partly done" rating in virtual versus in-person encounters (z = 3.92, p_adj = 0.001). CONCLUSIONS:Overall communication scores may be comparable across modalities, but some individual communication items may function differently in virtual versus in-person formats. Such differences may reflect modality-related variation in item proficiency, differences in rater scoring, or both. Threshold analysis offers a nuanced approach to evaluating comparability of OSCE formats by examining whether an observed rating reflects the same level of underlying communication proficiency across modalities.

BACKGROUND:Medication non-adherence contributes to the efficacy-effectiveness gap in real-world practice. Glucosuria, routinely measured on urinalysis, may serve as an objective proxy for assessing medication adherence to sodium-glucose cotransporter 2 (SGLT2) inhibitors, a class of medications that reduce the risks of kidney disease, heart failure, and mortality. METHODS:We leveraged two cohorts from the Optum Labs Data Warehouse real-world data (2014-2023): Cohort 1 included 3,987 patients with SGLT2 inhibitor pharmacy claims and a urinalysis performed both before and during active fill periods; cohort 2 included 45,711 patients prescribed SGLT2 inhibitors with urinalysis performed within 6 months after initiation. Glucosuria was defined as urine glucose 2+ or greater. Cohort 2 was followed for a mean of 3.3 years for all-cause mortality, heart failure hospitalization, end-stage kidney disease; fractures were used as a negative control outcome. RESULTS:In cohort 1, SGLT2 inhibitor use (vs. no use) was associated with 18.1-fold higher odds of glucosuria (95% CI, 16.4-20.0), adjusted for diabetes status. In cohort 2, 26,657 (58%) had glucosuria within 6 months of SGLT2 inhibitor initiation, suggesting adherence. After inverse probability of treatment weighting, glucosuria was associated with lower risks of all-cause mortality (HR, 0.78; 95% CI, 0.73-0.83), heart failure hospitalization (HR, 0.87; 95% CI, 0.78-0.98), and end-stage kidney disease (HR, 0.73; 95% CI, 0.58-0.91) compared to no glucosuria. No association was observed with fractures (HR, 1.00; 95% CI, 0.95-1.06). CONCLUSIONS:Glucosuria was associated with SGLT2 inhibitor adherence and, among patients prescribed SGLT2 inhibitors, is associated with reductions in risks of all-cause mortality, heart failure, and end-stage kidney disease.

BACKGROUND/UNASSIGNED:Individuals with opioid use disorder (OUD) who return to the community from incarceration face a high risk of fatal drug overdose. This mortality risk is related to significant barriers to accessing health care, social support, and resources needed to transition to and thrive within the community safely. Digital health tools have effectively supported substance use treatment and recovery, but their potential to support OUD during the high-risk period of reentry is underexplored. OBJECTIVE/UNASSIGNED:This study aimed to examine how adults with OUD returning from incarceration perceive and engage with digital health tools, and identify barriers and facilitators to their use. METHODS/UNASSIGNED:Semistructured interviews were conducted with a purposive sample of 39 adults recently released from New Hampshire prisons and jails. Participants were recruited from a randomized clinical trial (EXIT-CJS) comparing the effectiveness of extended-release buprenorphine, naltrexone, and enhanced treatment as usual on treatment retention. Interviews were audio recorded, transcribed, and analyzed using a deductive-inductive approach to content analysis. The COREQ (Consolidated Criteria for Reporting Qualitative Research) criteria were used to guide the study reporting. RESULTS/UNASSIGNED:Most participants preferred digital health over in-person care for both OUD treatment and other health care, mainly due to its convenience and resilience against reentry challenges. Yet, most participants also underscored the irreplaceable role of in-person therapeutic human connection in recovery and recognized this as a trade-off of stand-alone digital health. Participants described using digital health tools to overcome barriers that otherwise would have prevented them from receiving in-person care, such as transportation shortages, limited provider availability, and work scheduling conflicts. Accessing digital health was acknowledged as contingent on access to internet-capable devices, affordable connectivity, and digital literacy. CONCLUSIONS/UNASSIGNED:The findings suggest that maximizing digital health's impact in reentry will require a multipronged approach: investing in infrastructure to close the digital divide, addressing upstream structural barriers to accessing care, and partnering with impacted persons to co-design hybrid care models that enhance the feasibility of engaging in care during reentry while enhancing therapeutic human connection and respecting patient preferences.

DESCRIPTION/UNASSIGNED:In December 2025, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) released a clinical practice guideline (CPG) update on lipid management for cardiovascular disease risk reduction in adults. This synopsis reviews the 2025 updates and describes the major recommendations. METHODS/UNASSIGNED:The VA/DoD guideline development team updated the 2020 VA/DoD lipid management CPG with clinical stakeholders. The guideline panel developed 12 key questions, systematically evaluated the literature (English-language publications from 16 May 2019 to 15 January 2025), and developed 24 evidence-based recommendations. The recommendations were graded using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. RECOMMENDATIONS/UNASSIGNED:This synopsis highlights key recommendations for lipid management that are new or differ from other guideline recommendations. This update recommends the Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) calculator for risk estimation in primary prevention and removes a previous recommendation against routine lipid monitoring. Two new risk refinement strategies were added: Coronary artery calcium testing is suggested for patients with clinical uncertainty and intermediate-to-high calculated risk, and one-time lipoprotein(a) testing is recommended to identify patients with enhanced cardiovascular risk. For primary prevention, moderate-intensity statins remain the recommended treatment for those at higher risk and should be considered for those at intermediate risk. A new recommendation suggests moderate-intensity statins for adults living with HIV even when 10-year risk is low. This update shifts toward more intensive lipid-lowering therapy for secondary prevention. For very high-risk patients with atherosclerotic cardiovascular disease, the guideline now suggests combination therapy with high-intensity or maximally tolerated statins plus ezetimibe and/or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. For statin-intolerant patients, alternatives include bempedoic acid, ezetimibe, fibrates, or PCSK9 monoclonal antibody inhibitors.

PURPOSE/UNASSIGNED:Microhematuria may be a sign of underlying genitourinary pathology, but diagnoses of bladder cancer are rare among those who complete evaluations. This study determines the incidence of bladder cancer in a large cohort of patients with microhematuria, assesses the diagnostic potential of current guideline recommendations, and characterizes the relative risks of clinicodemographic factors to inform the need for microhematuria evaluation. MATERIALS AND METHODS/UNASSIGNED:microhematuria. The main outcome was a new bladder cancer diagnosis within 2 years of index urinalysis with microhematuria. Patients were stratified by American Urologic Association risk categories to compare guideline-based risk classification with model-based estimation. The Fine-Gray method was used to estimate adjusted associations between clinicodemographic characteristics and incident bladder cancer, accounting for the competing risk of death. RESULTS/UNASSIGNED:Among 267,133 patients with microhematuria, the two-year cumulative incidences of cystoscopy completion and a new bladder cancer diagnosis were 11.9% (95% CI 11.7, 12.0) and 1.5% (95% CI 1.4, 1.5), respectively. Older age, male sex, smoking history, and ≥25 RBC/hpf were associated with a new bladder cancer diagnosis when adjusted for competing risk of death. Performance of our bladder cancer prediction model was better (ROC AUC=0.63) than that of the current AUA guidelines (AUC=0.52, p<0.001) and allowed for further risk-estimation of patients designated "high risk" by AUA criteria. CONCLUSIONS/UNASSIGNED:Estimation of patient-level microhematuria-related bladder cancer risk is possible with readily available clinicodemographic factors. Current approaches lack nuance, particularly among "high risk" patients. Precision approaches that use relative risk-factor weights and/or novel diagnostic tools may improve individualized decision-making for evaluation.