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The authors describe a patient whose persistent left superior vena cava was first suspected because of difficulty in placing a right internal jugular venous catheter.

Case In Point: A patient with persistent left superior vena cava

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Clinical Topics

Hard Purple Nodules: Your Dx?

A 66-year-old woman had a mildly pruritic rash on the buttocks, lower back, abdomen, and upper posterior thighs. The eruption had been present for approximately 18 months.

A 66-year-old woman had a mildly pruritic rash on the buttocks, lower back, abdomen, and upper posterior thighs. The eruption had been present for approximately 18 months. Your diagnosis?

“Swimsuit Area” Rash: Your Dx?

"I'm not sure that mainstream medicine has embraced the concept that lifestyle interventions can be a managing strategy for remission of type 2 diabetes or at least for de-escalation of medications."

Lifestyle Medicine for Type 2 Diabetes: Is Mainstream Medicine Ready to be All In?

A new clinical practice guideline from the American College of Lifestyle Medicine (ACLM) moves treatment recommendations for 

 (T2D) into a realm that will be familiar to primary care clinicians and others who treat the metabolic disease but a realm of disease management that may typically be secondary to use of medication. 

Lifestyle interventions for treatment and remission of type 2 diabetes and prediabetes in adults: a clinical practice guideline from the American College of Lifestyle Medicine,

 for the first time, places broad-based lifestyle interventions at the center of care for adults prediabetes, T2D, and gestational diabetes.

The guideline offers clinicians a structured, evidence-based framework for not just integrating 

t into routine diabetes management, but for using the multifactorial approach as the primary "prescription." Unlike prior guidelines that acknowledge the importance of lifestyle change but don't offer  practical direction, this document delivers actionable strategies for implementing and sustaining behavioral change, according to the ACLM.

Guideline lead author Richard Rosenfeld, MD, MPH, MBA, talked with 

 recently about the evolution of the guideline and the focus on remission of disease. He acknowledged that some of the guideline's 14 "key action statements" might be more difficult to operationalize in primary care than others. He discusses that in more detail above; a transcript of his comments follow here, edited lightly for clarity and flow.     

Lifestyle Interventions for Treatment and Remission of Type 2 Diabetes and Prediabetes in Adults, 

has 14 key action statements. Thinking about primary care clinicians, which of these will be straightforward and which more difficult to implement?

 I think the gestalt here is that we start by perhaps stating the obvious. We do what other guidelines don’t. We start off by saying: listen—at the most fundamental level, you need to understand why these lifestyle interventions are important, and advocate for them. Encourage your patients to embrace them as an empowering way to manage their diabetes or prediabetes. And we provide tools for that—even just the process of thinking about it.

Then it gets into assessing baseline lifestyle habits and establishing what the priorities are for the person with diabetes or prediabetes, in terms of their goals and their readiness to change. It’s really the kind of stuff that people often take for granted and don’t even think about.

We then get into the six pillars of lifestyle medicine, with attention to coaching, behavior change, sustaining change, and de-escalating medications. I think two things are going to be particularly hard.

In the so-called "fish discover water last" scheme of thinking, I’m not sure that mainstream medicine has fully embraced the concept that lifestyle interventions can be a management strategy for remission of type 2 diabetes—or at least for de-escalation of medications—and for preventing gestational diabetes or prediabetes from progressing to full-blown type 2 diabetes. It’s not taught in school. Residency programs don’t emphasize this. So it’s a bit of a sea change in thinking.

The other thing I think will be tough is achieving person-centered and sustained behavior change. Getting people to make changes and assessing readiness to change is relatively straightforward if you do it right. But keeping them on the path—that’s tough. Sustaining change is hard. We know that from decades of work in weight loss: people sign up for a gym membership on January 1, and stop going by February 1.

So these strategies for coaching, for peer support, family support, professional support, cognitive behavioral therapy—other strategies to promote and sustain change—are going to be tough, but essential.

For an at-a-glance preview of the 14 lifestyle interventions recommended in the guideline, see 

Guideline Topline: 14 Key Lifestyle Interventions to Treat, Prevent Type 2 Diabetes

Richard Rosenfeld, MD, MPH, MBA, is the distinguished professor of otolaryngology, SUNY Downstate Health Sciences University and senior advisor for quality and guidelines for the American Academy of Otolaryngology – Head and Neck Surgery. Rosenfeld is board certified in otolaryngology – head and neck surgery and in lifestyle medicine.

. Rosenfeld RM, Grega ML, Karlsen MC, et al. Lifestyle interventions for treatment and remission of type 2 diabetes and prediabetes in adults: a clinical practice guideline from the American College of Lifestyle Medicine. 

 First clinical practice guideline on lifestyle interventions for treatment and remission of type 2 diabetes and prediabetes in adults is published. News release. American College of Lifestyle Medicine. June 10, 2025. Accessed June 11, 2025. https://prnmedia.prnewswire.com/news-releases/first-clinical-practice-guideline-on-lifestyle-interventions-for-treatment-and-remission-of-type-2-diabetes-and-prediabetes-in-adults-is-published-302477850.html

Richard Rosenfeld, MD, MPH, MBA, lead author of new guidelines on sustained lifestyle change as central to treating, even reversing T2D, answers the question. 

This image of the dorsum of the tongue of a 42-year-old African American woman shows parallel linear black coatings.

After a “swig” of  Kaopectate, this patient noticed tongue discoloration. Is this coincidental, or is there a clinical connection? 

Black Coating on a Woman’s Tongue

Falls are a leading cause of injury, hospitalization, and loss of independence in adults aged 65 and older in the US. More than 1 in 4 adults in the age category experience a fall each year, adding up to  more than 14 million fall episodes annually.

The scope of the consequences won't be a surprise to primary care clinicians who are involved in care for their older patients who fall before, during, and after an accident: more than 3 million emergency department visits and more than 36,000 deaths occur annually as a result of falls in this population.

  The consequences on an individual level are no less concerning. In addition to being a precursor to loss of personal agency, later-life falls are also linked to decreased quality of life and increased risk of needing residential care. 

The burden is high, but falls are not an inevitable part of aging. There is a wide range of evidence-based interventions that can reduce fall risk and support older adults in maintaining mobility and autonomy. Those typically top of mind include regular physical activity, particularly balance and strength training, and home safety modifications. Equally important, and included in the 5 reminders in the slide above, are regular reviews of medication to reduce polypharmacy and drug-drug interactions, cross disciplinary management of vision and hearing impairments, and uncomplicated access to regular health care through training on and use of telehealth technology and transportation support.

Importantly, the most successful fall prevention efforts require a multifactorial approach tailored to each individual’s risk profile. Click through this short slide show for a topline refresher on 5 of the primary areas you'll want to assess for each older patient.   

Moreland B, Kakara R, Henry A. Trends in nonfatal falls and fall-related injuries among adults aged ≥65 years—United States, 2012–2018. 

Older adult falls data. Older adult fall prevention. CDC. Updated October 8, 2024. Accessed July 8, 2025. 

National Center for Injury Prevention and Control. WISQARS™ Injury Data. Accessed July 8, 2025. 

https://www.cdc.gov/injury/wisqars/index.html

Exercise and strength/balance training are keys to protecting against falls, but careful assessments at each clinic visit may uncover other risks to address.

Mahmoud Traina, MD

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