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Effective Resources for PAD

Peripheral artery disease (PAD) is a clinical manifestation of atherosclerosis, which occurs when atherosclerotic plaque narrows arteries and decreases blood flow to the legs. An estimated 8 to 10 million people have PAD, and the disease is most prevalent in older persons. Individuals with atherosclerotic risk factors are at increased risk for PAD. Two of the cardinal risk factors are cigarette smoking and diabetes; patients who either smoke or have diabetes are two to four times more likely to develop PAD than others.  As atherosclerosis is a systemic disorder, patients with PAD are at increased risk of having coronary artery disease and cerebrovascular disease, and consequently myocardial infarction, stroke, and cardiovascular death. Risk factor modification and antiplatelet therapy are indicated to prevent these adverse cardiovascular events. About 10% of people with diabetes older than 40 have PAD, but many who show warning signs don’t realize that they have it and will not get treated for it. The most characteristic symptom is intermittent claudication, variably described as an ache, cramp pain, or fatigue in the calf, thigh, or even buttocks, that develops while walking and resolves with rest, among others.  Severe PAD may cause foot pain at rest, and result in skin ulceration or gangrene. If PAD is not detected, then appropriate therapies to reduce the risk of cardiovascular events, improve leg symptoms, and prevent limb loss may not be instituted in a timely manner. Screening is Paramount According to current American College of Cardiology/American Heart Association guidelines, screening for PAD is recommended for all patients with diabetes older than 50, people older than 50 who smoke, and everyone older...

A Strategy to Prevent Postoperative Pneumonia

Postoperative pneumonia continues to create a burden on healthcare systems, often leading to increases in morbidity, length of hospital stay, and costs. Postoperative pneumonia is the third most common complication among surgical patients and is the third most common infectious complication after urinary tract and wound infections. Despite the availability of effective antibiotics, published research indicates that mortality rates associated with hospital-acquired pneumonia due to gram-negative infection are between 25% and 50%. The overall prognosis for patients experiencing postoperative pneumonia is poor, due in part to comorbidities.  “Postoperative pneumonia is the third most common complication among surgical patients and is the third most common infectious complication after urinary tract and wound infections.” According to the Institute for Healthcare Improvement, a facility that performed 10,000 non-cardiac operations per year would be expected to have about 150 cases of postoperative pneumonia. In the ICU, this complication can translate into additional healthcare costs of as much as $40,000 per patient; the estimated mortality rate ranges from 20% to 70%. Throughout the country, pneumonia-prevention programs have been successfully implemented in ICU settings. However, there are currently no such programs in place for patients in surgical wards. An Effective Pilot Program In the April 2010 Journal of the American College of Surgeons, my colleagues and I reported a study in which we tested a pilot pneumonia-prevention program to assess its effect on reducing the incidence of postoperative pneumonia in a hospital surgical ward. The pilot prevention program was designed and implemented based on an extensive literature review of risk reduction interventions. In the program, physicians and ward staff received education on preventing pneumonia. Other...

Helpful Guidelines for Heart Health in Diabetes

This Physician’s Weekly feature covering guidelines for heart health in diabetes was completed in cooperation with the experts at the American Diabetes Association. Research has shown that patients with diabetes are at two to four times greater risk of suffering cardiovascular disease (CVD) events when compared with patients who do not have diabetes. Several mechanisms have been linked to the increased CVD risk in people with diabetes, including increased intracoronary thrombus formation, elevated platelet reactivity, and worsened endothelial dysfunction. “Aspirin has been shown to be effective in reducing cardiovascular morbidity and mortality in high-risk patients with heart attack or stroke,” explains Craig D. Williams, PharmD. “However, there has been some confusion surrounding the use of aspirin in patients who do not yet have CVD. That confusion is even greater among patients with diabetes.” In 2007, the American Diabetes Association and the American Heart Association (AHA) jointly recommended that aspirin be used as a primary prevention strategy in patients with diabetes who are at increased cardiovascular risk. This patient group includes those who are older than 40 or who have additional risk factors, such as a family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria. “These recommendations were derived from older trials that included fewer patients with diabetes,” says Dr. Williams. “We now have results from two recent randomized controlled trials—the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes and the Prevention of Progression of Arterial Disease and Diabetes trials—in which aspirin use was examined specifically in patients with diabetes. These studies provide important insights on the efficacy of aspirin for primary prevention in diabetes, but they have also...

Medicare Payment Cut to MDs Delayed — For Now

The U.S. House of Representatives voted to delay a 23% Medicare payment cut to physicians that was scheduled for Wednesday, December 1, according to the Associated Press. The one-month delay will provide physicians with a short-term reprieve to a looming crisis over treatment of the nation’s elderly.   Many doctors have threatened to stop accepting new Medicare patients if the cut went ahead. “While this short-term delay helps ensure that physicians can continue to care for seniors for the next month, congressional action early in December to stop the cut for one year will inject stability into the Medicare program and ensure that Medicare delivers on its promise of health coverage for America’s seniors,” Cecil Wilson, a physician who serves as president of the American Medical Association, said in a statement. “It is crucial that Congress act well before the January 1 deadline so there are no disruptions in care for seniors.” Delaying the cut will hopefully provide lawmakers more time to adopt the year-long extension that seniors and doctors need. This extension would give time to create a new way to pay doctors for Medicare services.  However, unless Congress passes further legislation next month, doctors will face another huge cut January. The Medicare payment formula was established by Congress in 1997. The formula associates the spending on doctors to growth of the economy, measured by the gross domestic product. Many doctors want to eliminate the formula because costs are rising much faster than Medicare payment...
Eat Your Sweet Potatoes This Thanksgiving and Live Longer!

Eat Your Sweet Potatoes This Thanksgiving and Live Longer!

A large study just released by the CDC found that consumption of high levels of alpha carotene appears to reduce the risk of dying of all causes by up to 39%. The 14-year study assessed the direct relationship between alpha-carotene concentrations and risk of death among more than 15,000 U.S. adults. The authors reported significant associations between serum alpha-carotene concentrations and the risk of death from cardiovascular disease, cancer, and all other causes. Most people are familiar with the more widely known antioxidant, beta-carotene, but researchers are suggesting that alpha-carotene may be around 10 times more effective than beta-carotene in inhibiting the development of cancer cells. Published in the current online issue of Archives of Internal Medicine, the study found that — compared with individuals with blood alpha-carotene levels between 0 and 1 µg/dL — the risk of death during the study period was 23% lower among those who had concentrations between 2 and 3 µg/dL, 27% lower with levels between 4 and 5 µg/dL, 34% lower with levels between 6 and 8 µg/dL and 39% lower with levels of 9 µg/dL or higher. Alpha-carotene is found in high concentrations of yellow-orange vegetables, such as carrots, sweet potatoes, and pumpkins and dark green vegetables, such as broccoli, spinach, and leaf lettuce. Findings from the study support increasing fruit and vegetable consumption as a way of preventing premature...

Setting the Stage for Good Nutrition in Diabetes

This Physician’s Weekly feature covering nutritional recommendations and interventions for diabetes was completed in cooperation with the experts at the American Diabetes Association.  Medical nutrition therapy (MNT) is an important part of preventing prediabetes and diabetes, managing existing diabetes, and preventing or slowing the rate of the development of diabetes complications. MNT is also an integral component of diabetes self-management education and training. The goals of MNT are to achieve and maintain healthy A1C, blood pressure, and cholesterol levels by modifying the intake of nutrients and improving lifestyle behaviors. “The United States has about 57 million people with pre-diabetes, and most of these people have problems with being overweight and obese,” says Wahida Karmally, DrPH, RD, CDE, CLS, FNLA. “In addition, people with diagnosed diabetes are often already overweight or obese. Using MNT and increasing physical activity are paramount to managing these individuals.” Clinical practice recommendations on MNT, which are based on scientific evidence, have recently been updated by the American Diabetes Association. Available at http://care.diabetesjournals.org, the recommendations can assist clinicians as they provide MNT to patients and offer strategies for specific patient groups (Table 1). “With MNT, it’s important to address individual nutrition needs,” says Dr. Karmally. “That requires taking into account personal and cultural preferences as well as willingness to change. Another goal is to help people maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence.” Assessing the Evidence Clinical trials and outcome studies of MNT have reported decreases in A1C of about 1% in type 1 diabetes and 1% to 2% in type 2 diabetes, depending on the duration of...

Preventing Diabetes Complications to Improve Outcomes

More than 84 million people in America have diabetes or are on the verge of getting it, and 90% of these people have type 2 diabetes. Between 2002 and 2007, the cost of diabetes-related complications to the United States healthcare system more than doubled from $24.6 billion to $58 billion. In many cases, type 2 diabetes can be managed or avoided with lifestyle changes like weight loss and exercise. Unfortunately, many people with type 2 diabetes struggle to find the motivation needed to make these changes. As a result, they are experiencing life-altering complications such as heart attack, stroke, blindness, limb amputation, and kidney failure at alarming rates. New Survey Data A survey commissioned by Boehringer Ingelheim Pharmaceuticals and conducted by Sermo recently convened a multidisciplinary steering committee to assess attitudes about diabetes-related complications. It showed that complications are prevalent in type 2 diabetes. More than 40% of physicians surveyed said that over half of their patients develop at least one complication as a result of uncontrolled type 2 diabetes. Nearly all physicians surveyed (94%) believed that kidney health is an important consideration in understanding the risk of other complications, but 40% did not believe the majority of their newly diagnosed patients even know that type 2 diabetes can lead to kidney disease. “To reduce the disease burden, complications related to type 2 diabetes must be decreased.” Physicians participating in the survey reported that lack of motivation, lack of medication adherence, and an inability to lose weight were the most common reasons for ineffective control of their patients’ type 2 diabetes. Compliance with lifestyle modifications and medications and poor...
Preventing Diabetes Complications Improves Outcomes

Preventing Diabetes Complications Improves Outcomes

A recent survey found that more than 80% of physicians believe that a team of specialists designated to help in the early stages of type 2 diabetes may help improve patient outcomes. However, 93% did not believe their peers were utilizing this strategy. For more results on this survey and strategies to reduce complications in diabetes, be on the watch for next week’s feature, Preventing Diabetes Complications to Improve Outcomes. Register for the Physician’s Weekly eNewsletter to receive links to our featured articles of the week, health news, physician interviews, and...

Light Technology Zaps Hospital Superbugs

A lighting system appears to be able to kill hospital superbugs—including MRSA and C. Difficile—by decontaminating the air and exposed surfaces in a narrow spectrum of visible-light wavelengths, known as HINS-light. Clinical trials from the University of Strathclyde in Glasgow, Scotland, have shown that HINS-light significantly reduces bacterial pathogens in the hospital environment than can be achieved by cleaning and disinfection alone. This technology may provide hospitals with an additional effective means to prevent the spread of hospital-acquired infections—a crisis plaguing hospitals around the world. A narrow spectrum of visible-light wavelengths is used to excite molecules contained within bacteria. This in turn produces highly reactive chemical species that are lethal to bacteria, such as meticillin-resistant Staphylococcus aureus and Clostridium difficile. Traditional disinfection and sterilization methods have significant limitations. Unlike other decontamination methods such as those involving gas sterilants or UV-light, HINS-light is harmless to patients and staff. Furthermore, the pervasive nature of light permits the  treatment of air and all visible surfaces, regardless of accessibility, either through direct or reflected exposure to HINS-light within the treated environment. This enables hospitals to continuously disinfect wards and isolation...

Battling Obesity: Improving Interactions with Patients

Healthcare providers have frequent interaction with patients struggling with their weight. It’s estimated that 60% of doctors’ office visits are filled with people who are overweight or obese. While new diagnostic and treatment options to battle obesity continue to be investigated, recognition is rarely given to the social consequences of obesity. Negative stereotypes and patient-provider interactions can lead to poor emotional and physical health among those who are obese. These factors can also lead to disparities in quality of care among high-risk individuals. Weight Discrimination In a recent survey, over 2,000 Americans were polled to determine the role of weight discrimination in society. The prevalence rates of weight discrimination were comparable to that of racial discrimination; among women, weight discrimination was actually higher than racial discrimination. Another survey compared a cohort from two different time periods, finding that rates of weight discrimination have increased by 66% in the past decade. An analysis of 2,400 overweight and obese adults recently found that the most common frequently reported source of weight stigma was from doctors (69%), followed closely by nurses (46%), dietitians (37%), and mental health professionals (21%). These findings emphasize that healthcare professionals are not immune to negative attitudes toward obese people. Weight discrimination can occur in both subtle, nonverbal ways and in overt ways. Negative stereotypes include obese patients being perceived as lazy, less competent, dishonest, noncompliant, and lacking in motivation and self-discipline. To determine if bias is present, providers should consider the following: Do I make assumptions based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors? Am I comfortable working with...

Conference Highlights: 2010 Society of Interventional Radiology Meeting

The Society of Interventional Radiology held its 2010 annual meeting from March 13 to 18 in Tampa, Florida. The features below highlight some of the news emerging from the meeting. For more information on these items and other research that was presented, go to www.sirmeeting.org. » Preventing Strokes During Carotid Artery Stenting » Abnormal ABI Indicative of Cardiovascular Events » Vertebroplasty Relieves Pain for Osteoporotic VCFs Preventing Strokes During Carotid Artery Stenting The Particulars:Until recently, most carotid artery stenting procedures have been performed with filters in order to remove debris. The FDA has cleared a proximal cerebral protection device (Mo.Ma, Invatec) for use during carotid artery stenting. It suspends blood flow and prevents debris from traveling to the brain. Data Breakdown:Investigators evaluated the safety and effectiveness of the proximal cerebral protection device in 262 patients with carotid artery disease considered high risk. The 30-day major adverse cardiac and cerebrovascular events rate was 2.7%, a finding below the performance goal of 13% set before the start of the study. The major stroke rate was 0.9% through to the end of the trial; the death rate was also 0.9%. Take Home Pearls: Use of a proximal cerebral protection device may be able to prevent strokes during carotid stenting procedures. Results add to the body of data to support stenting as an alternative to surgery. Abnormal ABI Indicative of Cardiovascular Events [back to top] The Particulars:The ankle-brachial index (ABI) test is a noninvasive blood pressure reading in the ankle used to screen for peripheral artery disease (PAD). The ABI may provide another way to identify cardiovascular risks in older patients not considered...

Public Awareness of Specialized Stroke Hospitals

When managing stroke, time is brain. Every minute that stroke therapy is delayed can make a major difference in outcomes for patients. Appropriate treatment of stroke requires a well-organized, protocol-driven, evidence-based approach to meet treatment goals. Goals include seeing patients with stroke symptoms within 15 minutes, performing a CAT scan and having it read within 25 minutes, and treating patients with tPA within an hour of their arrival. The challenge for physicians is that all of these goals must be accomplished within a limited amount of time. Primary Stroke Center Certification In an effort to improve stroke outcomes and eliminate disparities in access to acute stroke centers, the Joint Commission developed a primary stroke center certification program in collaboration with the American Stroke Association (ASA). The program encourages hospitals and medical centers to apply for a Certificate of Distinction for Primary Stroke Centers in order to be recognized as a center that makes exceptional efforts to improve performance measures in the treatment of stroke. Achievement of certification signifies that the services provided have the critical elements to achieve long-term success in improving outcomes. In order to receive certification, centers must have the appropriate infrastructure in place—including personnel and protocols—to deal with acute stroke and collect different data points so that performance can be tracked. Centers must also offer public education about stroke and medical education for members on the stroke service team. “Every minute that stroke therapy is delayed can make a major difference in outcome.” The Joint Commission monitors certified centers longitudinally, using numerous performance indicators, to validate that the center is meeting certification parameters. Previous studies have...

Effective Approaches to Managing Newly Diagnosed Diabetes Patients

This Physician’s Weekly feature covering effective approaches to managing newly diagnosed diabetes patients was completed in cooperation with the experts at the American Diabetes Association. According to the American Diabetes Association, 23.6 million children and adults in the United States have diabetes, 25% of whom are undiagnosed. Approximately 1.6 million new cases of diabetes are diagnosed in people aged 20 and older each year. In addition, another 57 million people have pre-diabetes, a condition in which blood glucose levels are higher than normal but not yet high enough to be diagnosed as diabetes. People with pre-diabetes are at an increased risk of developing diabetes and cardiovascular disease. “Identifying diabetes and pre-diabetes early is critical because the earlier clinicians take measures to help patients with lifestyle changes and appropriate medication choices the most initial success they will have and the more successful they will likely be in the long run in controlling their disease and preventing diabetes complications,” says Richard M. Bergenstal, MD. Making the Diagnosis Historically, clinicians have used tests that are based on the measurement of plasma glucose to detect diabetes in people without symptoms. These tests include a fasting plasma glucose (FPG) test or an oral glucose tolerance test (OGTT). Recently, the American Diabetes Association suggested adding the A1C test as another diagnostic tool for identifying diabetes and pre-diabetes (Figure 1). The A1C test reflects the average amount of glucose in the blood over the last 2 to 3 months, and is not affected by short-term physical and emotional stresses that can temporarily affect a blood glucose test. “A1C tests are accurate and precise, and offer several advantages...

Overcoming the Hurdles of Insulin Initiation

This Physician’s Weekly feature covering insulin initiation and strategies to overcome hurdles was completed in cooperation with the experts at the American Diabetes Association. According to current recommendations for the management of type 2 diabetes, timely initiation of both oral medications alone or in combination with insulin therapy is paramount to ensuring a desired level of glycemic control and improved patient outcomes. Although most providers agree that insulin is an effective approach to treating diabetes, many still consider it a last resort. “Patients are hesitant to take insulin for a variety of reasons,” says Mary T. Korytkowski, MD. “It is important that providers understand some of the barriers that exist among patients for insulin initiation as a way of reducing some of the negative attitudes many express to this form of therapy as a way of ensuring good outcomes.” Before initiating insulin, it can be helpful to obtain an understanding of a patient’s view of insulin therapy. “When patients express apprehension, efforts to identify the reasons underlying this apprehension or refusal to take insulin can provide clinicians with the information they need to improve acceptance,” Dr. Korytkowski says. “Insulin therapy means different things to different people. When barriers exist, it is important to determine the level of concern among patients and ask open-ended questions [Figure 1]. Responses to such questions allow for the ability to follow up with additional inquiries that can help guide physicians to better understand and support their patients’ concerns.” Assessing Patient Barriers Several common patient related barriers to insulin initiation have been identified. These include: Beliefs that insulin is a personal failure. Beliefs that insulin...
Early Observations From Look AHEAD

Early Observations From Look AHEAD

Type 2 diabetes continues to adversely impact life expectancy, quality of life, and medical costs. Compounding the problem is that obesity among patients with diabetes is also increasing, further impacting the potential for future improvements in life expectancy and quality of life for these patients. It has been well established that the excess morbidity and mortality experienced by people with diabetes is primarily due to increased cardiovascular disease (CVD) risk, specifically the triad of hyperglycemia, hypertension, and hyperlipidemia. People with type 2 diabetes die about 8 years earlier than those without the disease, primarily due to their increased risk of CVD. Interventions to reduce the adverse health outcomes of diabetes are primarily directed at cardiovascular risk factors, but despite these efforts most patients do not appear to be achieving optimal care goals for CVD risk reduction. Clinical studies have demonstrated that effective programs for people with diabetes that achieve long-term weight loss and increase physical activity are promising for improving cardiovascular risk while minimizing use of pharmacologic agents. More research continues to explore the role of lifestyle interventions in these patients. The Look AHEAD (Action for Health in Diabetes) study is an ongoing NIH trial, which is examining the effect of an intensive lifestyle intervention (ILI) on CVD morbidity and mortality in people with diabetes. The ILI includes group and individual meetings to achieve and maintain weight loss by decreasing caloric intake and increasing physical activity; the comparator is a traditional diabetes support and education intervention (DSE). In the June 2010 issue of Diabetes Care, my colleagues and I examined the effect of the Look AHEAD intervention on medication...
Physician's Weekly eNewsletter Wins Web Health Award

Physician's Weekly eNewsletter Wins Web Health Award

Physician’s Weekly eNewsletter has been named a winner in the 12th annual Web Health Awards program, which recognizes the best in digital health information. Our weekly eNewsletter delivers feature articles interviewing experts in medicine, trending health news, eBooks, and more! Sign up to receive the Physician’s Weekly eNewsletter. The goal of the Web Health Awards is to recognize high-quality electronic health information. The program is an extension of the Health Information Resource Center’s 17-year-old National Health Information Awards, the largest program of its kind in the United...

Diabetics Shown to Benefit from Lifestyle Intervention

Lifestyle interventions have thus far more than doubled the percentage of diabetic participants achieving optimal care goals in The Look AHEAD (Action for Health and Diabetes) study, an ongoing National Institute of Health trial examining the effect of an intensive lifestyle intervention on CVD morbidity and mortality in diabetics. It has been well established that the increased morbidity and mortality experienced by people with diabetes are primarily due to increased cardiovascular disease (CVD) risk. For more details discussing the Look AHEAD trial, keep an eye out for our upcoming article, Early Observations From Look AHEAD.   Register for the Physician’s Weekly eNewsletter to receive links to our featured articles of the week, health news, physician interviews, and more....

Overcoming the Hurdles of Insulin Initiation

Insulin is generally viewed as an effective treatment for type 2 diabetes, but both physicians and patients often consider the drug a last resort. Identifying barriers and solutions to insulin initiation is critical to enhancing outcomes. Our upcoming feature, Overcoming the Hurdles of Insulin Initiation, helps physicians address the hurdles that may impede insulin initiation in their patients. Register for the Physician’s Weekly eNewsletter to receive links to our featured articles of the week, health news, physician interviews, and...
Diabetes Predicted to Strike 30% of Americans by 2050

Diabetes Predicted to Strike 30% of Americans by 2050

As many as 1 in 3 Americans could have diabetes in 40 years if current trends continue, according to a new analysis from the CDC. The incidence of diabetes is expected to rise from 8 newly diagnosed cases per 1,000 people in 2008 to 15 per 1,000 by 2050. The CDC and Emory University report, recently published in Popular Health Metrics, demonstrates that the rise in type 2 diabetes is primarily due to the continuously increasing overweight and obese population in this country. This projection assumes that recent increases in new cases of diabetes will continue, and people who have diabetes will also live longer, adding to the total number of people with the disease. The increase also is a reflection of the growth of diabetes internationally. According to the International Diabetes Federation, approximately 285 million people across the world had diabetes this year—a number expected to increase to 438 million by 2030. Risk factors for type 2 diabetes include older age, obesity, family history, having diabetes while pregnant, a sedentary lifestyle, and race/ethnicity.  African-Americans, Hispanics, American Indians/Alaska Natives, and some Asian-Americans and Pacific Islanders are at higher risk for the disease. CDC and its partners are working on a variety of initiatives to prevent type 2 diabetes and to reduce its...

Battling CKD in Patients with Diabetes

This Physician’s Weekly feature on chronic kidney disease and diabetes was completed in cooperation with the experts at the American Diabetes Association. Each year in the United States, more than 100,000 people are diagnosed with kidney failure, and diabetes is the most common cause of it, accounting for nearly 44% of new cases. Even when diabetes is controlled, it can lead to chronic kidney disease (CKD) and kidney failure. “According to current estimates, about 20% to 30% of people with diabetes have at least some CKD, although not necessarily end-stage renal disease,” explains M. Sue Kirkman, MD. “More patients with diabetes also have very early signs of kidney damage, such as microalbuminuria. Fortunately, we now have interventions to help prevent early CKD from progressing or worsening in people with diabetes.” Diabetic kidney disease takes many years to develop. In some patients, the filtering function of the kidneys is higher than normal in the first few years of the development of diabetes. Over several years, patients may develop low levels of albuminuria—termed microalbuminuria—but the kidneys’ filtration function usually remains normal during this period. Greater amounts of albuminuria (macroalbuminuria) occur in parallel with the kidneys’ filtering function declining, forcing the body to retain various wastes along the way. As kidney disease progresses, physical changes in the kidneys can increase blood pressure. As such, early detection and treatment of even mild hypertension are essential for people with diabetes. Early Screening is Imperative The American Diabetes Association recommends that every patient diagnosed with diabetes be screened for CKD (Table 1). “It’s better to diagnose it early and address problems at that time rather...
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