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Diabetes Update

Read some of our top diabetes-related articles on diabetic neuropathy, bariatric surgery, controlling glucose, and more....
Takin’ It to the Streets: New Recommendations for Driving & Diabetes

Takin’ It to the Streets: New Recommendations for Driving & Diabetes

Nearly 19 million people in the United States have diagnosed diabetes, and many of these individuals will seek or presently hold a license to drive. Currently, states have different laws concerning driving and diabetes. “For people with diabetes, a driver’s license is essential for many reasons, including getting to and from work or school, caring for themselves and/ or family members, and many other daily life functions,” says Daniel Lorber, MD, FACP, CDE. “This is an important issue because there has been considerable debate on the role of diabetes and its relevancy on determining driver ability and eligibility for a license.” He adds that each state has its own laws on disclosure of diseases that may impact patients’ driving ability, further complicating the issue. Click here to view our new Diabetes Update ebook. Research suggests most people with diabetes can and do drive safely, but in the past, there have been inappropriate attempts to restrict driving licensure for these patients. “The chief concern about driving with diabetes is hypoglycemia because these episodes can cause confusion and disorientation,” Dr. Lorber says. However, while hypoglycemic episodes can affect driving ability, the available data show that these incidents are uncommon. Other factors related to diabetes that could affect driving include retinopathy and peripheral neuropathy.   New Guidance In the January 2012 issue of Diabetes Care, the American Diabetes Association released a position statement based on current scientific and medical evidence addressing the issue of driving in patients with diabetes. The statement advises against blanket restrictions and instead recommends that patients who have issues that could increase driving risks be assessed by physicians...

More Patient Encounters Benefit Diabetes Care

As the epidemic of diabetes continues to grow, it’s becoming increasingly important for healthcare providers to find effective strategies to minimize microvascular and macrovascular complications associated with the disease. Unfortunately, many patients with diabetes do not have these disease components under control. Intriguing New Data In the Archives of Internal Medicine, my colleagues and I had a study published in which we retrospectively analyzed more than 26,000 patients with diabetes and hyperglycemia, hypertension, and/or hyperlipidemia who received care in primary care settings. We wanted to determine if diabetes control was improved with a greater frequency of patient encounters. A strong association between encounter frequency and A1C, blood pressure (BP), and LDL cholesterol control in patients with diabetes was observed (Table 1). Doubling the time between physician encounters was also found to increase median time to A1C, BP, and LDL cholesterol targets. More frequent opportunities for medication intensification are likely an important factor in our findings (Table 2). They may also likely improve medication adherence and increase opportunities for providers to offer lifestyle coaching or other education that can further enhance diabetes control. Potential for Great Benefits Considering that more frequent encounters in patients with diabetes would increase the demands on healthcare resources, increasing the frequency of encounters may require innovative approaches to delivering care. For example, medical homes may help coordinate the care of patients. In addition, some interactions could be accomplished through group visits, telephone, fax, email, or internet communications. Midlevel providers can also alleviate physician workloads without negatively affecting patient outcomes. Until guidelines provide more data or recommendations on how frequently patients with diabetes should be seen...
Walk This Way

Walk This Way

A CDC report has found that walking prevalence among American adults has increased since 2005, but investigators add that almost half fail to get enough exercise to improve their...

2012 VEITHsymposium: Meritorious Highlights, Trial Results, and Insight

Innovative Questions in Vascular Surgery Addressed at the 39th Annual VEITHsymposium In New York. At the 39th VEITHsymposium, vascular experts will provide trial results and insight into some novel questions in vascular surgery, including new wound healing materials, vascular obstructions in multiple sclerosis, endovascular approaches to upper extremity disease and vascular treatment for erectile dysfunction. Wednesday, November 14: Dressing material for donor site wounds (DSWs) after split-skin grafting: Dr. Fleur E Brölmann of the Academic Medical Center at the University of Amsterdam (Netherlands) will present the results of a multicenter randomized trial of wound dressings. In the study, researchers compared six commonly-used dressing materials for donor-site wounds after split-skin grafting in 289 patients. They found that that hydrocolloid dressings lead to a shorter healing time than the other materials. In contrast, gauze dressings were found to increase the risk of infection. Thursday, November 15: Multiple Sclerosis and Chronic Cerebrospinal Venous Insufficiency: The existence of chronic cerebrospinal venous insufficiency and its possible role in multiple sclerosis remain controversial. Dr. Andrew Nicolaides, Director of the Vascular Noninvasive Screening and Diagnostic Centre (London, United Kingdom), will discuss the data, which support the hypothesis that in the absence of cerebral venous obstruction, MS does not manifest or is mild in form. However, when accompanied by obstruction of these vessels, MS can take on more severe symptoms. Thursday, November 14: Endovascular Therapy for Vasculogenic Erectile Dysfunction: It’s estimated that up to 50% of men with erectile dysfunction have an inadequate response to phosphodiesterase-5 inhibitor (PDE-5i) therapy (e.g. sildenafil) therapy and discontinue this treatment. As a result, there is renewed interest in the diagnosis and...

What Do Interns Do When They’re on Call?

You may be surprised and dismayed when you find out. A study in the Journal of General Internal Medicine from a VA hospital affiliated with the University of Wisconsin reveals some startling facts. During a 14-hour call period of 3 pm to 5 am, medical interns spent 40% of their time on computer work and 30% on “non-patient communication,” such as clinical conversations with team members, other physicians and nurses among other things. Direct patient care accounted for a whopping 12% of their time. What about teaching and learning? Would you believe 2% of the time? The study was conducted using observers trained in time-motion research. They followed the 25 interns who volunteered for the project, but did not interact with them or influence them in any way. The study was likely much more accurate than most previous research on this topic, which was based on self-reported surveys of house staff. Other interesting tidbits from the paper were that the on-call intern cross-covered an average of 27 patients per night, which seems like a lot to me. The amount of time spent on “sign out” or “hand offs” was not stated. They averaged 4 admissions per night. Only 93 minutes [11% of the total time on call] were devoted to “downtime” — that is sleeping, eating and recreational computer time.  So that’s about 1.5 hours for sleeping, eating and surfing the Internet. So it looks like internal medicine interns at the VA in Wisconsin do a lot of “scut work” and don’t have much time for learning or sleeping. With only 4 admissions per night, you would think there...

FDA Approves Synribo for Chronic Myelogenous Leukemia

The U.S. Food and Drug Administration today approved Synribo (omacetaxine mepesuccinate) to treat adults with chronic myelogenous leukemia (CML), a blood and bone marrow disease. An estimated 5,430 people will be diagnosed with CML in 2012, according to the National Institutes of Health. Synribo is intended to be used in patients whose cancer progressed after treatment with at least two drugs from a class called tyrosine kinase inhibitors (TKIs), also used to treat CML. Synribo blocks certain proteins that promote the development of cancerous cells. It is injected just under the skin (subcutaneously) twice daily for 14 consecutive days over a 28-day cycle until white blood cell counts normalize (hematologic response). Synribo is then administered twice daily for seven consecutive days over a 28-day cycle as long as patients continue to clinically benefit from therapy. “Today’s approval provides a new treatment option for patients who are resistant to or cannot tolerate other FDA-approved drugs for chronic or accelerated phases of CML,” said Richard Pazdur, M.D., director of the Office of Hematology and Oncology Products in FDA’s Center for Drug Evaluation and Research. “Synribo is the second drug approved to treat CML in the past two months.” On Sept. 4, 2012, the FDA approved Bosulif (bosutinib) to treat patients with chronic, accelerated or blast phase Philadelphia chromosome positive CML who are resistant to or who cannot tolerate other therapies. Synribo is approved under the FDA’s accelerated approval program, which allows the agency to approve a drug to treat a serious disease based on clinical data showing that the drug has an effect on a surrogate endpoint that is reasonably likely...

TCT 2012: Stent With Mesh Covering Achieves Positive Outcomes

The Particulars: Covered stents have been studied for use in embolic protection, but their tightly women material tended to squeeze friable material out like toothpaste rather than trap it. The investigational MGuard stent uses a loosely interlaced mesh and may trap material that may otherwise plug up small vessels downstream. Data Breakdown: German research found that 58% of patients with acute who received the MGuard stent as part of emergent PCI achieved complete resolution of the ST-segment of a myocardial infarction (MI), indicating ischemia, within 60 to 90 minutes. The rate for those who received standard stents was 45%. A significantly higher proportion of patients who received MGuard had restoration of full perfusion to the heart when compared with those who received standard stents. Take Home Pearl: Among patients with acute ST segment elevation MI undergoing emergent PCI, the MGuard stent appears to achieve superior rates of epicardial coronary flow and complete ST-segment resolution when compared with standard...

TCT 2012: PFO Closure Device Superior to Medical Management in Repeat Stroke Prevention

The Particulars: It has been estimated that patent foramen ovale rates are three times higher in patients with cryptogenic stroke than in the general population. However, the superiority of PFO closure over standard medical therapy for secondary stroke prevention has not been demonstrated in a clinical trial. Data Breakdown: University of Colorado investigators compared standard medical treatment to the Amplatzer PFO Occluder—a wire mesh device inserted into a PFO to seal the passageway between the left and right atria—in prevention of recurrent stroke. Event rates at 2 years were 1.6% for the device and 3.0% for medical treatment. The clinical risk reduction of stroke with the device ranged from 46.6% to 72.7% compared with medical management alone. Take Home Pearl: Study results suggest than an investigational device to close a PFO appears to be superior to medical management alone in preventing a repeat...

TCT 2012: Stroke Risk With PCI vs. CABG

The Particulars: Research does not clearly indicate whether stroke risk is lower for patients who undergo PCI or for those who undergo CABG. Data Breakdown: A meta-analysis of 83 trials involving nearly 23,000 patients who underwent PCI, on-pump CABG, or off-pump CABG found significantly lower rates of 30-day stroke with PCI than with off-pump CABG (odds ratio = 0.39) or on-pump CABG (OR = 0.26). While initial results suggested that off-pump CABG was associated with significantly lower stroke rates than on-pump CABG (OR= 0.67), the difference was no longer significant after stratifying results from high-quality trials, trials with more than 100 patients, and those with a definition for Clinical Events Committee adjudication of stroke. Take Home Pearls: PCI appears to be associated with a lower risk of stroke than either on-pump CABG or off-pump CABG. Off-pump CABG appears to be associated with a lower, but not statistically different, risk of stroke than on-pump...

TCT 2012: TAVR Successful in a Real-World Setting

The Particulars: Previous research indicates that favorable results can be achieved with transcatheter aortic valve replacement (TAVR) in high-risk patients use either the transfemoral or transapical approach. Whether these results are reproducible in a real-world setting has not been determined. Data Breakdown: A nonrandomized cohort of the PARTNER (Placement of AoRtic TraNscathetER valve) trial found significantly lower 30-day, in-hospital rates of stroke, stroke/transient ischemic attack (TIA), major vascular injury, and valve embolization than found in the randomized trial in patients who underwent TAVR using the transapical approach. With the transfemoral approach, patients in the nonrandomized cohort had lower rates of 30-day, in-hospital stroke and TIA. With both approaches, 1-year outcomes favored those in the nonrandomized cohort. Take Home Pearl: It appears that the favorable results achieved with TAVR in high-risk patients in the randomized PARTNER trial are reproducible in a real-world...

TCT 2012: Renal Nerve Ablation Achieves Long-Term Blood Pressure Benefits

The Particulars: Treatment options are limited for patients with refractory high blood pressure (BP). Renal nerve ablation represents a potentially beneficial, minimally invasive option for this patient population. Data Breakdown: In an Australian study, patients with refractory high BP were treated with radiofrequency ablation of renal artery nerves for 36 months. Of these, 41% had a diastolic BP of 140 mm HG or less and 45% had a diastolic BP under 160 mm Hg. Patients receiving the intervention also experienced an average reduction of 31 mm Hg in systolic BP. An immediate response to the procedure was observed in 69% of patients at 1 month, 96% at 30 months, and 94% at 36 months. Take Home Pearl: Treatment of refractory high BP with renal nerve ablation appears to have long-term, sustained benefits in reducing...

TCT 2012: Managing Atherosclerotic Popliteal Artery Stenosis

The Particulars: Few studies have compared primary stenting approaches with balloon angioplasty in patients with atherosclerotic popliteal artery stenosis. Balloon angioplasty is the current gold standard treatment. Data Breakdown: A trial compared primary stenting using a contemporary nitinol stent device with balloon angioplasty. At 1 year after treatment, 67.4% of patients who received the nitinol stent had patent popliteal arteries, compared with a 44.9% rate for those treated with balloon angioplasty. Outcomes at 1 year were similar for death, heart attack, amputation, and ankle brachial index, but more patients undergoing angioplasty required repeat treatment than those receiving nitinol stents. Take Home Pearls: Treatment of popliteal artery obstructive lesions with a nitinol self-expanding stent appears to be safe and improve both target lesion revascularization rates and 1-year primary patency...

TCT 2012: Reducing Cardiovascular Events in Patients With ACS

The Particulars: Dual antiplatelet therapy with aspirin and a P2Y12 platelet inhibitor has been beneficial in patients with unstable angina or non-STEMI. However, the optimal dual antiplatelet therapy strategy is unknown for many of these patients who do not undergo revascularization after angiography. Data Breakdown: More than 7,000 patients with acute coronary syndromes (ACS) who were medically managed without revascularization and had at least one high-risk criterion participated in an international investigation. Patients who were triaged to receive aspirin and prasugrel, a P2Y12 platelet inhibitor, following angiography had lower rates of heart attack, stroke, and recurrent ischemic events. These patients also had a lower risk of meeting the combined endpoint of cardiovascular disease, hear attack, and stroke. Take Home Pearl: Dual antiplatelet therapy with aspirin and prasugrel appears to reduce cardiovascular events among patients with ACS who are managed medically following...

Metabolic Syndrome, Catheter Ablation, & AF

Atrial fibrillation (AF) is increasingly being viewed by clinicians as a modern-day epidemic, affecting more than 2.2 million adults in the United States. AF is strongly age-dependent, affecting 4% of people older than 60 and 8% of those older than 80. Alarmingly, about one-quarter of people aged 40 and older are expected to develop AF during their lifetime. Another growing problem is the continued emergence of metabolic syndrome (MS), which is estimated to affect 21% to 24% of U.S. adults. Coexistence of MS and AF is common. Studies suggest that different components of MS, including hypertension, diabetes, dyslipidemia, and obesity, increase the likelihood of AF. Catheter ablation has been a major treatment advance for the condition, offering a new spectrum of options for drug-refractory AF patients. However, this procedure is yet to be a total success in maintaining long-term sinus rhythm, even in the best hands. Little is known about the role of MS on the long-term outcome of AF ablation, such as restoration of sinus rhythm and improvement in quality of life (QOL). Taking a Deeper Look at Atrial Fibrillation In the April 3, 2012 Journal of the American College of Cardiology, we had a study published that prospectively analyzed 1,496 patients with AF who were undergoing a first ablation. About 45% of our study group had long-standing persistent AF, while 29% had paroxysmal AF and 26% had persistent AF. Patients were classified as either having MS or not having MS. They were followed for AF recurrence and QOL at 12 months after their ablation procedure. At follow-up, 39% of patients with MS had experienced arrhythmia recurrence, compared...

Hypertrophic Cardiomyopathy: A Welcome Guideline Update

Hypertrophic cardiomyopathy (HCM) is one of the most common genetic heart diseases in the United States, affecting approximately 600,000 to 700,000 people. In many cases, patients remain unidentified. This, in part, may explain why few cardiology practices have the opportunity to evaluate HCM patients nationwide. In 2003, the American College of Cardiology (ACC) and European Society of Cardiology created an expert consensus panel on HCM. The ACC and the American Heart Association (AHA) revisited the topic with the publication of guidelines in the December 13, 2011 issues of Circulation and the Journal of the American College of Cardiology. “HCM has become a highly treatable disease thanks to new management strategies, but many physicians are still challenged with managing it,” says Barry J. Maron, MD, who co-chaired the ACC/AHA guideline update writing committee. “We took this opportunity to clarify the most important diagnostic and management strategies. Many of the recommendations in the 2011 guidelines are similar to those in the 2003 consensus document, but newer data have provided a better understanding of these recommendations, particularly in the areas of prevention of sudden death and genetic testing.” Hypertrophic Cardiomyopathy Recommendations According to the ACC/AHA guidelines, treatment of patients with HCM must be individualized and requires an understanding of the complex pathophysiology and natural history of the disease. According to Dr. Maron, the three areas of greatest importance are use of prophylactic defibrillators, management of outflow tract obstruction, and application of genetic testing. Implantable cardioverter defibrillators (ICDs) for the prevention of sudden cardiac death are the only treatment known to prolong life in this disease, says Dr. Maron. The generally agreed upon...

Analyzing Pediatric Return Visits

An average of 698,000 pediatric return visits to the ED within 72 hours occurred each year between 2001 and 2007, accounting for 2.7% of all ED visits, according to data from the National Hospital Ambulatory Medical Care Survey. Return visits were associated with: Age younger than 1. Ages 13 to 18. ED arrival between 7:00 AM and 3:00 PM. Recent hospital discharge. Western region of the United States. The authors added that insurance was not associated with return visits to the ED in pediatric patients. Abstract: Pediatric Emergency Care, July...

Medicaid Visits Often for Urgent & Serious Symptoms

National study results suggest that the majority of ED visits made by non-elderly Medicaid patients are for urgent or more serious medical issues, a finding that is contrary to the popular belief that such visits in this population are usually for routine care. In a study, nonurgent symptoms accounted for just 10% of visits made by non-elderly Medicaid patients, compared with 7% of visits made by privately insured nonelderly patients. Abstract: HSC Research Brief No. 23, July...

Delayed ED Care for the Morbidly Obese

The disposition home for morbidly obese patients appears to take significantly longer than that of people who are normal weight or mildly obese, according to a comparison of ED medical records for the two patient groups. Those with BMIs greater than 40 kg/m2 had an average length of stay of 388 minutes, compared with 287 minutes for those with a BMI less than 35 kg/m2. When compared with others, morbidly obese patients were also significantly more likely to undergo CT scans. Abstract: American Journal of Emergency Medicine, June...

New Balloon Catheter Hits Market

The FDA has approved a torqueable percutaneous transluminal coronary angioplasty balloon catheter (Glider PTCA Catheter, TriReme Medical, Inc.) for treating the stenotic portion of coronary arteries or bypass grafts to improve myocardial perfusion. The catheter is available with a balloon length of 4 mm and is designed for focal lesions. Source: TriReme Medical,...
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