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A New Diabetes Screening Tool to Promote Early Detection

Research has shown that more than 60 million adults in the United States have diagnosed diabetes, undiagnosed diabetes, or prediabetes. “Approximately 30% of diabetes cases are estimated to be undiagnosed,” says Heejung Bang, PhD. “Diabetes is a silent killer and many patients don’t know they have it, but clinicians can help patients by steering them to assess their risk on their own. With the steadily increasing prevalence of the disease, prevention of diabetes has become a major health priority, and the identification of high-risk people who may benefit from early lifestyle interventions is paramount.” National guidelines for diabetes screening are available to help detect undiagnosed disease. In addition, several risk assessment tools for prevalent or incident diabetes have been developed to identify patients who are most in need of screening. In the United States, national guidelines for diabetes screening have been released by the CDC, the American Diabetes Association (ADA), and the Preventive Services Task Force. In addition, two risk-scoring algorithms for undiagnosed diabetes have been derived from nationally representative samples. These methods have been developed using slightly different frameworks and purposes, but they are not widely used. “They often target specific populations,” says Dr. Bang, “and therefore may not be applicable to the general population, or may not be that simple to use.” A New Screening Tool In the December 1, 2009 Annals of Internal Medicine, Dr. Bang and colleagues had a study published detailing the development of a new screening score for undiagnosed diabetes in multi-ethnic U.S. adults by using readily-available health information. “Our aim was to improve existing algorithms for diabetes-risk scoring by using more contemporary...

2010 Heart Rhythm Society

The Heart Rhythm Society held its 2010 annual scientific sessions from May 12 to 15 in Denver. The features below highlight some of the news emerging from the meeting. CRT Devices Improve Mortality in Women The Particulars: Historically, women have been significantly under-represented in large cardiac resynchronization therapy (CRT) device trials. Researchers conducted a sub-study of the Multicenter Automatic Defibrillator Implantation Trial-CRT (MADIT-CRT); 25% of the participants in MADIT-CRT were women. Data Breakdown: Patients were randomly assigned to receive CRT device therapy or implantable cardioverter defibrillators. CRT device therapy was associated with a 34% overall reduction of death and heart failure (HF) in minimally symptomatic patients. Women received a significant benefit from CRT device therapy by reducing all-cause mortality by 72%. HF and death end points in the female population were reduced by 69%, compared with a 28% rate for the male population. Take Home Pearls: Women appear to receive a clinically significant benefit from CRT devices. This therapy appears to reduce all-cause mortality as well as HF and death in women. Post-Op AF Rates Lower in African Americans The Particulars: More than 2 million Americans are living with atrial fibrillation (AF). Risk factors known to be associated with AF include gender, age, hypertension, diabetes, and cardiovascular disease. Race had previously not been considered a risk factor, but recent data have shown a correlation. Data Breakdown: A study examined 1,001 adults without prior AF who underwent CABG surgery. African American patients had a higher prevalence of risk factors associated with AF, compared with Caucasian patients, but only 18% of African Americans developed postoperative CABG AF, compared with a 29%...

Updated Guidelines for Heart Failure

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have updated their guidelines on the diagnosis and management of heart failure (HF). Published jointly in the April 14, 2009 issues of Circulation and the Journal of the American College of Cardiology, the new document revised guidelines previously released in 2005. They reflect the latest research findings on the management of HF, a condition that affects approximately 5.7 million Americans. “The purpose of the guideline update is to provide clinicians with recommendations for care using the best-available evidence,” says Mariell Jessup, MD, FACC, FAHA, who chaired the ACCF/AHA writing committee that updated the guidelines. “The new recommendations are based on randomized clinical trials and important registry data whenever possible.” Key Revisions Among several key updates, the new guidelines incorporate recommendations about the management of acute HF in the hospitalized patient. In addition, the document includes concrete recommendations on the use of a fixed-dose combination of hydralazine and isosorbide dinitrate. The recommendation concerning hydralazine and isosorbide dinitrate was strengthened based on findings from the A-HeFT (African-American Heart Failure Trial) trial. “The complete evidence resulting from A-HeFT was not available at the time of the publication of the last guidelines in 2005,” says Dr. Jessup. “We therefore felt it was important to strengthen the recommendation to Class I so that all self-identified African Americans who remained symptomatic despite optimal medical therapy would be offered the hydralazine/isosorbide dinitrate combination.” In order to keep recommendations in alignment with those from the ventricular arrhythmia guidelines published by the ACCF/AHA, the document also clarifies previous recommendations surrounding the use of implantable cardioverter...

Redefining Screening Guidelines for Certain Cancers

According to the American Cancer Society, more than 40% of Americans will develop cancer at some point in their lifetime. It is also estimated that cancers that can be prevented or detected earlier by screening account for at least half of all new cancer cases. Estimates from 2009 indicate that about 192,370 women will be newly diagnosed with breast cancer, and another 40,170 will die from it. About 11,270 new cases of cervical cancer will be diagnosed in women, and 4,070 women will die from it. New cases of colorectal cancer will be diagnosed in 106,100 men and women and 49,920 of these people are estimated to die from the disease. Building on Previous Recommendations Considering the magnitude of these cancers, researchers at the University of Texas MD Anderson Cancer Center released comprehensive, risk-based screening guidelines for breast, cervical and colorectal cancers. Available at www.mdanderson.org, the recommendations translate best practices in cancer prevention employed at the university into accessible guidelines for the public to follow. It identifies risk categories and provides information about when to begin and discontinue screening exams. “The guidelines reconstruct and expand upon previously published guidelines for screening,” says Therese B. Bevers, MD, FAAFP. “The guidelines were developed by multidisciplinary panels of MD Anderson disease site experts across several areas.” Those areas include medical oncology, surgical oncology, cancer prevention, and imaging as well as others. Adjusting for Individual Risk “Cancer screening is not a one-size-fits-all strategy,” says Dr. Bevers. “The new risk-based recommendations from the University of Texas MD Anderson Cancer Center are more personalized, precise, and detailed than what has previously been released by other...

Analyzing Cardiovascular Risks With PAD

Peripheral arterial disease (PAD) is a highly prevalent but largely undiagnosed condition that affects an estimated 27 million people in Europe and North America. Caused by atherosclerotic occlusion of the leg arteries, PAD is associated with an increased risk of cardiovascular and cerebrovascular events, including death, myocardial infarction (MI), and stroke. It’s also associated with a higher total mortality compared with other manifestations of atherosclerosis. Despite an expanding treatment armamentarium for the condition, PAD patients continue to be undiagnosed and face a high incidence of cardiovascular events. A definitive diagnosis of PAD may not always be evident, even in symptomatic patients. For example, similar symptoms may be caused by arthritis of the hip or knee joint or by sciatica. A typical symptom is claudication in the legs—exertional pain while walking, particularly walking longer distances and up inclined surfaces. However, some patients may experience atypical claudication. Instead of describing their symptoms as exertional pain, patients may report that their legs are easily fatigued or cramp during the day with activity. This can easily be mistaken for old age; therefore, greater physician awareness of PAD overall and improved knowledge of atypical claudication may enhance the detection of PAD. Patients with asymptomatic PAD are still at increased risk of cardiovascular events, particularly MI and stroke. Other than the systemic risk associated with PAD, limb-threatening ischemia and amputation may also occur. However, the risk of developing limb-threatening ischemia is relatively low in patients with asymptomatic PAD. The CHARISMA Trial In an effort to improve the medical treatment of PAD, the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management and Avoidance (CHARISMA) trial...

Beta-Blockade: Minimizing Cardiac Risk During Non-Cardiac Surgery

An estimated 6 million people undergo non-cardiac surgery each year, and up to a quarter of these procedures (eg, major intra-abdominal, thoracic vascular, and orthopedic procedures) are associated with significant risk of perioperative cardiovascular morbidity and mortality. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) issued a practice guideline for the utilization of β-blockade in non-cardiac surgery. The update, published in the November 24, 2009 issue of Circulation and the Journal of the American College of Cardiology, identifies important new information regarding the risks and benefits of perioperative β-blockade. “Non-cardiac surgery represents a stress to the heart, particularly if the procedure is high risk or if patients have underlying risk factors for cardiac complications,” says Kirsten E. Fleischmann, MD, MPH, who chaired the committee that generated the focused update. As the aging population rises and the number of non-cardiac surgeries performed in them continues to increase, steps must be taken to minimize the risk of cardiac complications associated with these surgeries. Clinical Trial Evidence Drives Update Another impetus for the ACCF/AHA update was the publication of new randomized trial data, most notably the POISE (PeriOperative Ischemic Evaluation) and DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography)-IV trials. POISE confirmed that β-blocker therapy reduces perioperative cardiac events, but also clarified that routine perioperative β-blockade—particularly in fixed, higher-dose regimens initiated the day of surgery—was associated with risk. In POISE, the reduction in cardiac events was offset by a higher risk of stroke and death when using fixed higher-doses of metoprolol started on the day of surgery. The DECREASE-IV trial assigned intermediate cardiac risk patients to...

The 8 Rights of Safe EHR Use

The recent passage of the American Recovery and Reinvestment Act of 2009 stimulus package is putting tremendous pressure on physicians in small practices and larger healthcare organizations to implement state-of-the-art electronic health record (EHR) systems within the next 5 years. Incentive payments, beginning as early as 2011, will be allocated to healthcare facilities that meet the “meaningful use” EHR certification criteria, released by the CMS at the end of 2009. Currently, fewer than 20% of hospitals and less than 10% of physicians in private practice meet these criteria. Ideally, implementation of EHR systems should result in lower costs, less duplication, and greater quality of patient care. Hardeep Singh, MD, MPH, and I developed eight essential recommendations to ensure that EHRs are used safely and effectively. Published as a commentary in the September 9, 2009 JAMA, the “eight rights” were based on a systems engineering model for patient safety to realize the full potential of EHRs. These rights include: 1. Hardware or Software. The EHR system must have proper hardware and software to function correctly and ensure efficient workflow. 2. Content. Standardized terms used to describe clinical findings are necessary to ensure that information is shared effectively. 3. User Interface. User interface should allow clinicians to efficiently grasp a complex system in a way they can rapidly recognize and respond to problems. 4. Personnel. Trained and knowledgeable software designers, developers, trainers, and implementation and maintenance staff are essential for EHRs to work safely. 5. Workflow and Communication. Prior to system implementation, there should be careful workflow analyses and testing that account for EHR use. 6. Organizational Characteristics. Continual improvement relies...

Establishing Clear Criteria for Metabolic Syndrome

Metabolic syndrome is characterized by interrelated risk factors for cardiovascular disease (CVD) and diabetes, including dysglycemia, hypertension, raised triglyceride levels, low HDL cholesterol levels, and obesity, specifically central adiposity. Patients with metabolic syndrome are twice as likely to develop CVD over the next 5 to 10 years when compared with those without it. In addition, metabolic syndrome has been associated with a five-fold increase in risk for type 2 diabetes. Clarifying the Definition To unify the diagnostic criteria for metabolic syndrome, the International Diabetes Federation (IDF) recently issued a scientific statement in conjunction with the National Heart, Lung, and Blood Institute, American Heart Association, World Heart Federation, International Atherosclerosis Society, and International Association for the Study of Obesity. The statement, published in the October 19, 2009 issue of Circulation, defines terminology and criteria related to metabolic syndrome in an effort to clarify incongruencies presented by different organizations over the past decade. “It’s our hope that this joint statement will eliminate confusion and assist physicians with the identification and treatment of patients who have metabolic syndrome,” says Robert H. Eckel, MD, FAHA, a co-author of the scientific statement. Metabolic syndrome was first defined by a group at the World Health Organization in 1998; it emphasized insulin resistance as the major underlying risk factor. In 2001, the National Cholesterol Education Program Adult Treatment Panel-III (ATP III) characterized the syndrome as the presence of three of five risk factors (abdominal obesity, elevated triglycerides, low HDL cholesterol, high blood pressure, and elevated fasting glucose) with or without evidence of insulin resistance. Subsequently, the IDF established an alternative definition that required a threshold waist...
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