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Original Research | 
Christopher Y. Woo, MD; Erika J. Strandberg, MS; Michelle D. Schmiegelow, MD; Allison L. Pitt, MS; Mark A. Hlatky, MD; Douglas K. Owens, MD, MS; and Jeremy D. Goldhaber-Fiebert, PhD
Background:Cardiac resynchronization therapy (CRT) reduces mortality and heart failure hospitalizations in patients with mild heart failure. Objective:To estimate the cost-effectiveness of adding CRT to an implantable cardioverter-defibrillator (CRT-D) compared with implantable cardioverter-defibrillator (ICD) alone among patients with left ventricular systolic dysfunction, prolonged intraventricular conduction, and mild heart failure. Design:Markov decision model. Data Sources:Clinical trials, clinical registries, claims data from Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention life tables. Target Population:Patients age 65 years or older with a left ventricular ejection fraction (LVEF) of 30% or less, QRS duration of 120 milliseconds or more, and New York Heart Association (NYHA) class I or II symptoms. Time Horizon:Lifetime. Perspective:Societal. Intervention:CRT-D or ICD alone. Outcome Measures:Life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Results of Base-Case Analysis:Use of CRT-D increased life expectancy (9.8 years versus 8.8 years), QALYs (8.6 years versus 7.6 years), and costs ($286 500 versus $228 600), yielding a cost per QALY gained of $61 700. Results of Sensitivity Analyses:The cost-effectiveness of CRT-D was most dependent on the degree of mortality reduction: When the risk ratio for death was 0.95, the ICER increased to $119 600 per QALY. More expensive CRT-D devices, shorter CRT-D battery life, and older age also made the cost-effectiveness of CRT-D less favorable. Limitations:The estimated mortality reduction for CRT-D was largely based on a single trial. Data on patients with NYHA class I were limited. The cost-effectiveness of CRT-D in patients with NYHA class I symptoms remains uncertain. Conclusion:In patients with an LVEF of 30% or less, QRS duration of 120 milliseconds or more, and NYHA class II symptoms, CRT-D appears to be economically attractive relative to ICD alone when a reduction in mortality is expected. Primary Funding Source:National Institutes of Health, University of Copenhagen, U.S. Department of Veterans Affairs.
Topics: implantable defibrillators, heart failure, cost effectiveness, cardiac resynchronization therapy, cardiac resynchronization therapy defibrillator systems
Original Research | 
Patrick S. Twomey, MD; Bryan L. Smith, MD; Cathy McDermott, RN, MPH; Anne Novitt-Moreno, MD; William McCarthy, PhD; S. Patrick Kachur, MD; and Paul M. Arguin, MD
Background:Quinidine gluconate, the only U.S. Food and Drug Administration–approved treatment for life-threatening malaria in the United States, has a problematic safety profile and is often unavailable in hospitals. Objective:To assess the safety and clinical benefit of intravenous artesunate as an alternative to quinidine. Design:Retrospective case series. Setting:U.S. hospitals. Patients:102 patients aged 1 to 72 years (90% adults; 61% men) with severe and complicated malaria. Patients received 4 weight-based doses of intravenous artesunate (2.4 mg/kg) under a treatment protocol implemented by the Centers for Disease Control and Prevention between January 2007 and December 2010. At baseline, 35% had evidence of cerebral malaria, and 17% had severe hepatic impairment. Eligibility required the presence of microscopically confirmed malaria, need for intravenous treatment, and an impediment to quinidine. Measurements:Clinical and laboratory data from each patient's hospital records were abstracted retrospectively, including information from baseline through a maximum 7-day follow-up, and presented before a physician committee to evaluate safety and clinical benefit outcomes. Results:7 deaths occurred (mortality rate, 6.9%). The most frequent adverse events were anemia (65%) and elevated hepatic enzyme levels (49%). All deaths and most adverse events were attributed to the severity of malaria. Patients' symptoms generally improved or resolved within 3 days, and the median time to discharge from the intensive care unit was 4 days, even for patients with severe liver disease or cerebral malaria. More than 100 concomitant medications were used, with no documented drug–drug interactions. Limitation:Potential late-presenting safety issues might occur outside the 7-day follow-up. Conclusion:Artesunate was a safe and clinically beneficial alternative to quinidine. Primary Funding Source:Office of the Surgeon General, Department of the U.S. Army.
Topics: malaria, artesunate, malaria, falciparum, severe and complicated, investigational new drugs, quinidine
Ideas and Opinions | 
Adrian F. Hernandez, MD, MHS; Rachael L. Fleurence, PhD; and Russell L. Rothman, MD, MPP
Growing complexity and administrative burdens are making clinical trials less attractive to clinicians, health systems, sponsors, and patients. To address these challenges, the Patient-Centered Outcomes Research Institute created the National Patient-Centered Clinical Research Network (PCORnet), a “network of networks” to facilitate research that addresses important clinical questions. The authors discuss ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness), which will compare 2 different aspirin doses in high-risk patients with a history of heart disease while simultaneously testing PCORnet's capacity to accomplish its core mission.
Topics: aspirin, heart diseases, patient-centered care, comparative effectiveness research, compare 1 trial, clinical research, myocardial infarction, hemorrhage, cerebrovascular accident, ischemic stroke, follow-up, electronic medical records
Ideas and Opinions | 
Lindsay M. Jaacks, PhD; Mohammed K. Ali, MBChB, MSc, MBA; John Bartlett, MD; Gerald S. Bloomfield, MD, MPH; William Checkley, MD; Thomas A. Gaziano, MD, MSc; Douglas C. Heimburger, MD, MS; Sandeep P. Kishore, MD, PhD; Racquel E. Kohler, PhD, MSPH; Kasia J. Lipska, MD, MHS; Olivia Manders, MA; Christine Ngaruiya, MD, DTM&H; Robert Peck, MD, MS; Melissa Burroughs Pena, MD, MS; David A. Watkins, MD, MPH; Karen R. Siegel, PhD, MPH; and K.M. Venkat Narayan, MD, MSc, MBA
Noncommunicable diseases (NCDs) are among the leading causes of death and disability throughout the world. In September 2014, U.S. researchers met to discuss the challenges and opportunities in conducting global NCD research. This essay summarizes 4 strategies for moving forward on a global NCD research agenda.
Topics: communicable diseases, investments, mentors, world health, united states national institutes of health, disability
Ideas and Opinions | 
Jonathan Purtle, DrPH, MSc; John A. Rich, MD, MPH; Joel A. Fein, MD, MPH; Thea James, MD; and Theodore J. Corbin, MD, MPP
Violently injured patients are at risk for reinjury, violence perpetration, and posttraumatic stress; however, they have traditionally received in-hospital care that addresses only their physical injuries. The authors describe the organizational components of multidimensional, hospital-based violence intervention programs; evidence of the success of such initiatives; and how the Affordable Care Act may affect them.
Topics: hospitals, violence prevention
Research and Reporting Methods | 
Wendy P. Battisti, PhD; Elizabeth Wager, PhD; Lise Baltzer; Dan Bridges, PhD; Angela Cairns; Christopher I. Carswell, MSc; Leslie Citrome, MD, MPH; James A. Gurr, PhD; LaVerne A. Mooney, DrPH; B. Jane Moore, MS; Teresa Peña, PhD; Carol H. Sanes-Miller, MS; Keith Veitch, PhD; Karen L. Woolley, PhD; and Yvonne E. Yarker, PhD
This updated Good Publication Practice (GPP) guideline, known as GPP3, builds on earlier versions and provides recommendations for individuals and organizations that contribute to the publication of research results sponsored or supported by pharmaceutical, medical device, diagnostics, and biotechnology companies. The recommendations are designed to help individuals and organizations maintain ethical and transparent publication practices and comply with legal and regulatory requirements. These recommendations cover publications in peer-reviewed journals and presentations (oral or poster) at scientific congresses. The International Society for Medical Publication Professionals invited more than 3000 professionals worldwide to apply for a position on the steering committee, or as a reviewer, for this guideline. The GPP2 authors reviewed all applications (n = 241) and assembled an 18-member steering committee that represented 7 countries and a diversity of publication professions and institutions. From the 174 selected reviewers, 94 sent comments on the second draft, which steering committee members incorporated after discussion and consensus. The resulting guideline includes new sections (Principles of Good Publication Practice for Company-Sponsored Medical Research, Data Sharing, Studies That Should Be Published, and Plagiarism), expands guidance on the International Committee of Medical Journal Editors' authorship criteria and common authorship issues, improves clarity on appropriate author payment and reimbursement, and expands information on the role of medical writers. By following good publication practices (including GPP3), individuals and organizations will show integrity, accountability, and responsibility for accurate, complete, and transparent reporting in their publications and presentations.
Topics: steering committee, medical research, ethics, plagiarism, guidelines, data sharing
Topics: ankylosing spondylitis, cardiovascular system, mortality
Original Research | 
Nisha Nigil Haroon, MD, DM, DNB, MSc; J. Michael Paterson, MSc; Ping Li, PhD; Robert D. Inman, MD; and Nigil Haroon, MD, PhD, DM
Background:Ankylosing spondylitis (AS) is a chronic inflammatory arthritis affecting the spine in young adults. It is associated with excess cardiovascular and cerebrovascular morbidity. Objective:To determine whether patients with AS are at increased risk for cardiovascular and cerebrovascular mortality. Design:Population-based retrospective cohort study using administrative health data. Setting:Ontario, Canada. Patients:21 473 patients with AS aged 15 years or older and 86 606 comparators without AS, matched for age, sex, and location of residence. Measurements:The primary outcome was a composite of cardiovascular and cerebrovascular death. Hazard ratios (HRs) for vascular death were calculated, adjusted for history of cancer, diabetes, dementia, inflammatory bowel disease, hypertension, chronic kidney disease, and peripheral vascular disease and, among those aged 66 years or older, relevant drug therapies. Independent risk factors for vascular mortality were identified in patients with AS. Results:The mean age of patients with AS was 46 years, and 53% were male. Patients and comparators were followed for 166 920 and 686 461 patient-years, respectively. Adjusted HRs for vascular death in AS were 1.36 (95% CI, 1.13 to 1.65) overall, 1.46 (CI, 1.13 to 1.87) in men, and 1.24 (CI, 0.92 to 1.67) in women. Significant risk factors for vascular death were age; male sex; lower income; dementia; chronic kidney disease; peripheral vascular disease; and, among patients aged 65 years or older, lack of exposure to nonsteroidal anti-inflammatory drugs and statins. Limitation:Diagnosis codes for AS were not validated in Ontario. Conclusions:Ankylosing spondylitis is associated with increased risk for vascular mortality. A comprehensive strategy to screen and treat modifiable vascular risk factors in AS is needed. Primary Funding Source:The Arthritis Program, University Health Network, Toronto and The Arthritis Society, Canada.
Topics: diabetes mellitus, ankylosing spondylitis, kidney failure, chronic, diabetes mellitus, type 2, cancer, dementia, inflammatory bowel disease, cardiovascular system, mortality, hypertension, cerebrovascular disorders, peripheral vascular diseases, anti-inflammatory agents, non-steroidal
Reviews | 
Reed A.C. Siemieniuk, MD; Maureen O. Meade, MD; Pablo Alonso-Coello, MD, PhD; Matthias Briel, MD, MSc; Nathan Evaniew, MD; Manya Prasad, MBBS; Paul E. Alexander, MSc, PhD; Yutong Fei, MD, PhD; Per O. Vandvik, MD, PhD; Mark Loeb, MD, MSc; and Gordon H. Guyatt, MD, MSc
Background:Community-acquired pneumonia (CAP) is common and often severe. Purpose:To examine the effect of adjunctive corticosteroid therapy on mortality, morbidity, and duration of hospitalization in patients with CAP. Data Sources:MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through 24 May 2015. Study Selection: Randomized trials of systemic corticosteroids in hospitalized adults with CAP. Data Extraction:Two reviewers independently extracted study data and assessed risk of bias. Quality of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation system by consensus among the authors. Data Synthesis:The median age was typically in the 60s, and approximately 60% of patients were male. Adjunctive corticosteroids were associated with possible reductions in all-cause mortality (12 trials; 1974 patients; risk ratio [RR], 0.67 [95% CI, 0.45 to 1.01]; risk difference [RD], 2.8%; moderate certainty), need for mechanical ventilation (5 trials; 1060 patients; RR, 0.45 [CI, 0.26 to 0.79]; RD, 5.0%; moderate certainty), and the acute respiratory distress syndrome (4 trials; 945 patients; RR, 0.24 [CI, 0.10 to 0.56]; RD, 6.2%; moderate certainty). They also decreased time to clinical stability (5 trials; 1180 patients; mean difference, −1.22 days [CI, −2.08 to −0.35 days]; high certainty) and duration of hospitalization (6 trials; 1499 patients; mean difference, −1.00 day [CI, −1.79 to −0.21 days]; high certainty). Adjunctive corticosteroids increased frequency of hyperglycemia requiring treatment (6 trials; 1534 patients; RR, 1.49 [CI, 1.01 to 2.19]; RD, 3.5%; high certainty) but did not increase frequency of gastrointestinal hemorrhage. Limitations:There were few events and trials for many outcomes. Trials often excluded patients at high risk for adverse events. Conclusion:For hospitalized adults with CAP, systemic corticosteroid therapy may reduce mortality by approximately 3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately 1 day. Primary Funding Source:None.
Topics: community acquired pneumonia, glucocorticoids, inpatient, mechanical ventilation, steroid therapy, adrenal corticosteroids, mineralocorticoids, respiratory distress syndrome, adult
Editorials | 
Marcos I. Restrepo, MD, MSc; Antonio Anzueto, MD; and Antoni Torres, MD, PhD
In this issue, Siemieniuk and colleagues report a systematic review and meta-analysis of 13 randomized, controlled trials of adjunctive therapy with systemic corticosteroids versus placebo for patients hospitalized with community-acquired pneumonia. The editorialists discuss the review and call for changes in clinical practice.
Topics: adrenal corticosteroids, community acquired pneumonia, glucocorticoids, mineralocorticoids
Ideas and Opinions | 
Arif H. Kamal, MD, MHS; Jennifer M. Maguire, MD; and Diane E. Meier, MD
The United States is currently in the midst of a national crisis in providing accessible and responsive palliative care due to a shortage of professionals trained to provide this care. The authors suggest one possible approach for dealing with this crisis.
Topics: palliative care, workforce
Reviews | 
Jennifer H. Han, MD, MSCE*; Nancy Sullivan, BA*; Brian F. Leas, MS, MA*; David A. Pegues, MD; Janice L. Kaczmarek, MS; and Craig A. Umscheid, MD, MSCE
The cleaning of hard surfaces in hospital rooms is critical for reducing health care–associated infections. This review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included. Eighty studies were identified—76 primary studies and 4 systematic reviews. Forty-nine studies examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges or facilitators to implementation. Only 5 studies were randomized, controlled trials, and surface contamination was the most commonly assessed outcome. Comparative effectiveness studies of disinfecting methods and monitoring strategies were uncommon. Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.
Topics: disinfection, patients' rooms, therapeutic touch, healthcare associated infections, pathogenic organism, microbial colonization, touch sensation, contextual factors
In this issue, Han and colleagues' systematic review identifies gaps in the evidence base for hospital environmental cleaning. Unlike near-universal acceptance of the importance of hand hygiene, the prevailing view of the contribution of the inanimate health care environment to the spread of health care–associated infections swings back and forth. The editorialists underscore the need for carefully designed studies to help us understand the magnitude of contribution of the inanimate environment to the pathogenesis of these infections.
Topics: healthcare associated infections
Original Research | 
Alexander T. Sandhu, MD; R. Adams Dudley, MD, MBA; and Dhruv S. Kazi, MD, MSc, MS
Includes: Supplemental Content
Background:In 2014, the American Board of Internal Medicine (ABIM) substantially increased the requirements and fees for its maintenance-of-certification (MOC) program. Faced with mounting criticism, the ABIM suspended certain content requirements in February 2015 but retained the increased fees and number of modules. An objective appraisal of the cost of MOC would help inform upcoming consultations about MOC reform. Objective:To estimate the total cost of the 2015 version of the MOC program (“2015 MOC”) and the incremental cost relative to the 2013 version (“2013 MOC”). Design:Decision analytic model. Data Sources:Published literature. Target Population:All ABIM-certified U.S. physicians. Time Horizon:10 years (2015 to 2024). Perspective:Societal. Intervention:2015 MOC. Outcome Measures:Testing costs (ABIM fees) and time costs (monetary value of physician time). Results of Base-Case Analysis:Internists will incur an average of $23 607 (95% CI, $5380 to $66 383) in MOC costs over 10 years, ranging from $16 725 for general internists to $40 495 for hematologists-oncologists. Time costs account for 90% of MOC costs. Cumulatively, 2015 MOC will cost $5.7 billion over 10 years, $1.2 billion more than 2013 MOC. This includes $5.1 billion in time costs (resulting from 32.7 million physician-hours spent on MOC) and $561 million in testing costs. Results of Sensitivity Analysis:Costs are sensitive to time spent on MOC and MOC credits obtainable from current continuing education activities. Limitation:Precise estimates of time required for MOC are not available. Conclusion:The ABIM MOC program will generate considerable costs, predominantly due to demands on physician time. A rigorous evaluation of its effect on clinical and economic outcomes is warranted to balance potential gains in health care quality and efficiency against the high costs identified in this study. Primary Funding Source:University of California, San Francisco, and the Department of Veterans Affairs.
Topics: sensitivity analysis, american board of internal medicine
Tobacco is a “wicked problem,” which refers to complex social problems with large economic burdens that resist simple solutions and bedevil policymakers. This commentary discusses a recent Institute of Medicine report that addresses how agent-based models might guide tobacco control policy. These computational models explore how individual elements of the system behave as a function of individual characteristics or interactions with each other and with the environment.
Topics: institute of medicine (u.s.), tobacco use, tobacco
Reviews | 
Ethan M. Balk, MD, MPH; Amy Earley, BS; Gowri Raman, MD, MS; Esther A. Avendano, BA; Anastassios G. Pittas, MD, MS; and Patrick L. Remington, MD, MPH
Includes: Supplemental Content
Background:Trials have shown efficacy of rigorous diet and physical activity promotion programs to reduce diabetes incidence and improve glycemic measures in adults at increased risk for type 2 diabetes. Purpose:To evaluate diet and physical activity promotion programs for persons at increased risk for type 2 diabetes, primarily to reduce diabetes risk and decrease body weight and glycemia. Data Sources:MEDLINE, the Cochrane Central Register of Controlled Trials, CAB Abstracts, Global Health, and Ovid HealthSTAR from 1991 through 27 February 2015, with no language restriction. Study Selection:8 researchers screened articles for single-group or comparative studies of combined diet and physical activity promotion programs with at least 2 sessions over at least 3 months in participants at increased risk for type 2 diabetes. Data Extraction:7 researchers extracted data on study design; participant, intervention, and outcome descriptions; and results and assessed study quality. Data Synthesis:Fifty-three studies (30 of diet and physical activity promotion programs vs. usual care, 12 of more intensive vs. less intensive programs, and 13 of single programs) evaluated 66 programs. Compared with usual care, diet and physical activity promotion programs reduced type 2 diabetes incidence (risk ratio [RR], 0.59 [95% CI, 0.51 to 0.66]) (16 studies), decreased body weight (net change, −2.2% [CI, −2.9% to −1.4%]) (24 studies) and fasting blood glucose level (net change, −0.12 mmol/L [−2.2 mg/dL] [CI, −0.20 to −0.05 mmol/L {−3.6 to −0.9 mg/dL}]) (17 studies), and improved other cardiometabolic risk factors. Evidence for clinical events was limited. More intensive programs were more effective. Limitations:Wide variation in diet and physical activity promotion programs limited identification of features most relevant to effectiveness. Evidence on clinical outcomes and in children was sparse. Conclusion:Combined diet and physical activity promotion programs are effective at decreasing diabetes incidence and improving cardiometabolic risk factors in persons at increased risk. More intensive programs are more effective. Primary Funding Source:Centers for Disease Control and Prevention Community Preventive Services Task Force.
Topics: physical activity, diabetes mellitus, type 2, diet, diabetes prevention, diabetes mellitus
Reviews | 
Rui Li, PhD; Shuli Qu, MPH; Ping Zhang, PhD; Sajal Chattopadhyay, PhD; Edward W. Gregg, PhD; Ann Albright, PhD; David Hopkins, MD; and Nicolaas P. Pronk, PhD
Background:Diabetes is a highly prevalent and costly disease. Studies indicate that combined diet and physical activity promotion programs can prevent type 2 diabetes among persons at increased risk. Purpose:To systematically evaluate the evidence on cost, cost-effectiveness, and cost–benefit estimates of diet and physical activity promotion programs. Data Sources:Cochrane Library, EMBASE, MEDLINE, PsycINFO, Sociological Abstracts, Web of Science, EconLit, and CINAHL through 7 April 2015. Study Selection:English-language studies from high-income countries that provided data on cost, cost-effectiveness, or cost–benefit ratios of diet and physical activity promotion programs with at least 2 sessions over at least 3 months delivered to persons at increased risk for type 2 diabetes. Data Extraction:Dual abstraction and assessment of relevant study details. Data Synthesis:Twenty-eight studies were included. Costs were expressed in 2013 U.S. dollars. The median program cost per participant was $653. Costs were lower for group-based programs (median, $417) and programs implemented in community or primary care settings (median, $424) than for the U.S. DPP (Diabetes Prevention Program) trial and the DPP Outcome Study ($5881). Twenty-two studies assessed the incremental cost-effectiveness ratios (ICERs) of the programs. From a health system perspective, 16 studies reported a median ICER of $13 761 per quality-adjusted life-year (QALY) saved. Group-based programs were more cost-effective (median, $1819 per QALY) than those that used individual sessions (median, $15 846 per QALY). No cost–benefit studies were identified. Limitation:Information on recruitment costs and cost-effectiveness of translational programs implemented in community and primary care settings was limited. Conclusion:Diet and physical activity promotion programs to prevent type 2 diabetes are cost-effective among persons at increased risk. Costs are lower when programs are delivered to groups in community or primary care settings. Primary Funding Source:None.
Topics: physical activity, diabetes mellitus, type 2, diet, cost effectiveness, economics, community, life style
Clinical Guidelines | 
Nicolaas P. Pronk, PhD; and Patrick L. Remington, MD, MPH, on behalf of the Community Preventive Services Task Force*
Description:Community Preventive Services Task Force (Task Force) recommendation on the use of combined diet and physical activity promotion programs to reduce progression to type 2 diabetes in persons at increased risk. Methods:The Task Force commissioned an evidence review that assessed the benefits and harms of programs to promote and support individual improvements in diet, exercise, and weight and supervised a review on the economic efficiency of these programs in clinical trial, primary care, and primary care–referable settings. Population:Adolescents and adults at increased risk for progression to type 2 diabetes. Recommendation:The Task Force recommends the use of combined diet and physical activity promotion programs by health care systems, communities, and other implementers to provide counseling and support to clients identified as being at increased risk for type 2 diabetes. Economic evidence indicates that these programs are cost-effective.
Topics: physical activity, diabetes mellitus, type 2, diet, community, diabetes prevention
Annals Editors discuss their policy on publishing articles written by authors with ties to industry.
Topics: academia (organization)
In this issue, the Community Preventive Services Task Force delivers recommendations for healthcare systems and community organizations to offer combined diet and physical activity promotion programs that provide counseling and longitudinal support for persons at increased risk for type 2 diabetes. The editorialist notes that it is imperative that we promote these programs that have the potential to enable millions of Americans to evade a remaining lifetime burdened by the daily management of diabetes.
Topics: public health medicine, diabetes prevention, diet, diabetes mellitus, type 2
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