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Managing Inpatient Blood Glucose

Managing Inpatient Blood Glucose

Research indicates that hyperglycemia is a common finding among both medical and surgical patients, regardless of whether or not they have diabetes. When compared with patients who have normal glycemic levels, those with uncontrolled hyperglycemia have higher mortality and morbidity. These patients tend to have: • Delays in healing. • Poor immune responses. • Higher risks for cardiovascular events, inflammatory issues, and thrombosis. The extra care associated with these issues can increase healthcare costs unnecessarily. Need for Changes Many hospitals in the United States have protocols intended to implement intensive insulin therapy routinely in critically sick patients. However, based on new evidence, Amir Qaseem, MD, PhD, MHA, FACP, warns that physicians should not use intensive insulin therapy to strictly control blood glucose in hospitalized patients with or without diabetes. According to Dr. Qaseem, a potentially major harm in using intensive insulin therapy is that it can increase the risk of hypoglycemia. “This can lead to the same poor outcomes and adverse effects that we try to avoid with efforts to prevent or treat hyperglycemia,” he says. “Physicians should avoid aggressive glucose management and instead target levels of 140 mg/dL to 200 mg/dL when using insulin therapy.” Finding Balance To help clinicians find a balance between hyper­glycemia and hypoglycemia, Dr. Qaseem and colleagues at the American College of Physicians (ACP) reviewed recently published studies and developed recommendations on inpatient glycemic control. The document was published in the American Journal of Medical Quality. The first recommendation made by the ACP committee was that clinicians should avoid intensive insulin therapy to strictly control blood glucose or to normalize blood glucose in surgical...
Guidance for CRC Screening

Guidance for CRC Screening

Colorectal cancer (CRC) has been the subject of screening guidelines from multiple organizations, creating some confusion among caregivers over which has the highest-quality, evidence-based recommendations. Rather than developing an additional guideline on the topic, the American College of Physicians recently decided that it would be more valuable to provide information to clinicians based on a rigorous review of currently available guidelines. Making Sense of CRC Literature My colleagues and I developed this guidance statement using current recommendations from a joint guideline from the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology, as well as individual guidelines from the Institute for Clinical Systems Improvement, the U.S. Preventive Services Task Force, and the American College of Radiology. Based on our evaluations, we developed four guidance statements for CRC screening: 1. Clinicians should perform individualized assessment of risk for CRC in all adults. 2. Clinicians should screen for CRC in average-risk adults starting at age 50 and in high-risk adults starting at age 40 or 10 years younger than the age at which the youngest affected relative was diagnosed with CRC. 3. Clinicians should use a stool-based test, flexible sigmoidoscopy, or optical colonoscopy as a screening test in average-risk patients. Optical colonoscopy should be used in high-risk patients. Clinicians should select the test based on the benefits and harms of the test, availability of the test, and patient preferences. 4. Clinicians should stop screening for CRC in adults older than age 75 or in adults with a life expectancy of less than 10 years. The evidence reviewed in our guidance statement showed that...

New Treatment Guidelines for ED

Erectile dysfunction (ED) is a common disorder of male sexual function that affects all age groups, especially older people and those with diabetes, vascular diseases, psychiatric disorders, and possibly hypogonadism. The general population continues to age and life expectancy is expected to increase. When combined with the high prevalence of diabetes and cardiovascular disease, the healthcare burden and quality-of-life issues associated with ED may be substantial. In 1995, more than 152 million men throughout the world had experienced ED, and its prevalence is predicted to reach 322 million worldwide by 2025. Furthermore, recent estimates suggest that the cost of treating ED in the United States could reach $15 billion if all affected men sought care. Current pharmacologic therapies for ED include phosphodiesterase-5 (PDE-5) inhibitors and hormonal treatment. On November 3, 2009, the American College of Physicians (ACP) published a guideline in the Annals of Internal Medicinebased on systematic reviews and current evidence, which presents recommendations on hormonal testing and pharmacologic management for ED. Initiating & Selecting Therapy The ACP strongly recommends that therapy with a PDE-5 inhibitor be initiated in men who seek treatment for ED and who do not have a contraindication for using these drugs (Figure). Oral PDE-5 inhibitors have demonstrated statistically significant and clinically relevant improvements in sexual intercourse and erectile function. Overall, PDE-5 inhibitors were well tolerated and were associated with mild or moderate adverse events. The incidence of adverse events did not significantly differ among the available PDE-5 inhibitors. Nitrate therapy, however, is a contraindication for therapy with oral PDE-5 inhibitors. The ACP also recommends that clinicians base their choices of a specific PDE-5...
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