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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...

Managing Cognitive Decline in Older Adults With Diabetes

This Physician’s Weekly feature on managing cognitive decline in older adults with diabetes was completed in cooperation with the experts at the American Diabetes Association. More than 25% of Ameri­cans aged 65 and older has diabetes, and the aging of the overall population has been identified as a significant driver of the diabetes epidemic. “Diabetes in older adults is associated with higher mortality, reduced cogni­tive and functional status, and increased risk of institutionaliza­tion,” explains Hermes Florez, MD, PhD, MPH. “Importantly, diabetes has been linked to sig­nificantly higher risks of cogni­tive impairment, a greater rate of cognitive decline, and increased risk of dementia.” While various complications of diabetes are well known and well researched, the effect diabetes has on the brain has historically received relatively little attention. “The risk of both diabetes and cognitive impairment increases with age,” Dr. Florez says. “The presentation of cognitive impairment in people with diabetes can vary, ranging from subtle executive dysfunction to overt dementia and memory loss. We’re starting to see links between diabetes and dementia and Alzheimer’s disease, but researchers are still conducting analyses to further increase our knowledge on these associations.”  Consensus Report on Diabetes in Older Adults In the December 2012 issue of Diabetes Care, the American Diabetes Association released a consensus report on diabetes and older adults. Dr. Florez, who was on the writing group that developed the report, says that an important component to managing older adults with diabetes is the role of cognitive impairment. “For older patients with diabetes, treatments will need to be simplified whenever possible, and caregivers should be involved during consultations. The presence of cognitive...

Treating Hypertension: Opportunities Aplenty

Guidelines recommend that people with high blood pressure (BP) be prescribed medication and those on BP medications get a new one if their condition worsens or if BP control remains inadequate. It’s unclear how often these guidelines are followed on a national level. It’s likely that physicians are missing out on key opportunities to better control their patients’ high BP. Are Hypertension Guidelines Being Followed? In the September 24, 2012 Archives of Internal Medicine, my colleagues and I had a study published that analyzed new BP medication prescriptions for patients with uncontrolled hypertension. Using the National Ambulatory Medical Care Survey (NAMCS), we aimed to determine if physicians were following national recommendations and find out which factors influenced prescribing decisions. Data were reviewed on 16,473 visits between 2005 and 2009 for patients already diagnosed with high BP. Some patients were on BP medications, whereas others may have been told to bring their BP under control by other means, including lifestyle changes. “Empowering patients to discuss BP with their physicians may help us gain better control of the hypertension problem in the U.S.” According to our results, about 20% of the 7,153 visits by patients with uncontrolled hypertension— defined as 140/90 mm Hg and higher in the setting of a diagnosis of hypertension—resulted in new medications during doctors’ office visits. People with very high BP and those who specifically came to their doctor for hypertension were more likely to get a new prescription. Patients already on BP medications were less likely to get a new one. These factors remained highly significant in multivariable regression. Likelihood of New BP Medication Our findings...

Blood Pressure & End-Stage Renal Disease in Patients With CKD

Studies have shown that treating high blood pressure (BP) is one of the most important strategies to slowing the progression from chronic kidney disease (CKD) to end-stage renal disease (ESRD). Currently, a BP goal of less than 130/80 mm Hg is recommended for patients with CKD, a target lower than the goal recommended for people without CKD (less than 140/90 mm Hg). Despite the dissemination of clinical guidelines, meeting BP targets in people with CKD may be difficult in clinical practice. “The most recent evidence supporting the use of lower BP targets in people with CKD has been conflicting,” explains Carmen A. Peralta, MD, MAS. “The association of BP levels and ESRD risk in a large, national, community-based setting of persons with established CKD has not been well studied. In addition, some recent reports have found that higher pulse pressure and lower diastolic BP (DBP) may lead to adverse cardiovascular outcomes. This can make it especially challenging for clinicians to control BP aggressively in patients with CKD.” Associations Between BP and ESRD Few studies have investigated the association of each BP component with ESRD risk. In Archives of Internal Medicine, Dr. Peralta and colleagues had a study published that investigated the independent association of systolic BP (SBP) and DBP with ESRD risk in patients with CKD who participated in the Kidney Early Evaluation Program (KEEP), a nationwide kidney health screening program offered by the National Kidney Foundation. More than 16,000 patients in KEEP were studied in the analysis, all of whom had at least stage III CKD. “In the past, questions have been raised about the established BP targets...

Detecting Intimate Partner Violence More Quickly

Published research indicates that nearly one-third of women reported that they were presently experiencing some form of intimate partner violence (IPV) when they were asked about these occurrences during an ED visit. When questioned about their past, nearly 50% of women reported being victims of IPV. In addition, other research has demonstrated that 56% of victimized female patients presenting to the ED also report perpetration behaviors. Studies that have focused on detecting perpetrators of IPV in the ED suggest that screening is effective, but few of these individuals are actually identified in medical settings despite frequently being in attendance. Testing a Shorter Screening Tool for IPV The gold standard for detecting perpetrators of IPV in the ED has historically been the 25-question Physical Abuse of Partner Scale (PAPS). Although the PAPS is an effective, validated questionnaire, the length of time needed to administer it is not practical for a short visit in the ED. In the February 2012 Journal of Emergency Medicine, my colleagues and I had a study published in which we developed a shorter IPV screening alternative to the PAPS. We developed the PErpetration RaPid Scale (PERPS) by validating a shortened version of the PAPS consisting of three questions: 1. Have you ever forced your partner to have sex or hurt your partner during sex? 2. Have you ever pushed or shoved or poked your partner violently? 3. Have you ever hit or punched your partner’s arms, body, head, or face? Unlike the PAPS, which uses a Likert scale for its 25 questions, PERPS has the potential to be administered more quickly because it uses only “yes/no”...
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