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Diabetes Side Effects: Breaking the Silence

Diabetes Side Effects: Breaking the Silence

Sexual and urologic complications among men and women with diabetes have historically received relatively little attention from clinicians. Diabetes impacts the function and structure of the lower urinary tract, including the bladder and prostate. Studies suggest that urologic complications resulting from diabetes may be even more common than that of widely recognized microvascular complications, such as retinopathy, neuropathy, or nephropathy. “Diabetes can lead to different types of sexual and urologic complications in both men and women,” says Jeanette S. Brown, MD (Table 1). “These include urinary incontinence (UI), poor bladder emptying, sexual dysfunction, lower urinary tract symptoms (LUTS), and urinary tract infections (UTIs). Treatment options are available for many of these sexual and urologic complications. Unfortunately, these problems often go unaddressed because patients oftentimes will not discuss these issues with their clinicians.” Caring for Women: Lower Urinary Tract Symptoms Urinary incontinence has been estimated to be more common in women with type 2 diabetes than in women with normal glucose levels (Table 2). There is also evidence that women with pre-diabetes are at higher risk for incontinence. The clinical diagnosis of UI—and more broadly, LUTS—is typically based on a variety of factors, and Dr. Brown says that clinicians can be proactive by paying attention to patient complaints when they arise. “It can often be difficult for women to speak up when they develop issues like UI, LUTS, or UTIs, but we should be asking them about these symptoms regularly during office visits,” Dr. Brown says. “When symptoms are identified, we can then take that opportunity to educate patients about the possible treatment options that are available to manage these...
Should ED Wait Times Be Advertised?

Should ED Wait Times Be Advertised?

Throughout the country, many hospitals are advertising their services to the public using various marketing vehicles. Many of these advertisements prominently display ED wait times as a major selling point, suggesting that their wait times are short and convenient. Proponents of this practice say this is a powerful marketing strategy that can help steer patients to the ED, thus potentially increasing hospital revenue. This practice may also alleviate some of the burden on other hospitals because patients with less severe problems may opt to drive a little farther to a different hospital if they think the wait time will be shorter. Wait Times May Be Potentially Misleading Although there are potential gains for advertising ED wait times, it’s also important to recognize that this practice can be misleading. There are no clear standards on what advertised times represent. For example, it’s unknown at what point the clock starts and when it stops. Advertised wait times are merely an average number, but this can defeat the purpose of triage. ED patients are supposed to be evaluated based on the time-sensitivity of their condition rather than the order upon which they arrive. For laypeople, this fact may not be clear when they see an advertisement. The numbers on advertising wait times also don’t account for patients who need to be transferred or have care deferred to a follow-up visit with a specialist. Other factors may prolong wait times, especially if there are laboratory or radiology inefficiencies. These numbers also don’t describe the times that admitted patients may need to wait if there is a lack of available inpatient beds. Furthermore, advertising...
Gender Differences in Total Hip Arthroplasty

Gender Differences in Total Hip Arthroplasty

Research has shown that total hip arthroplasty (THA) can significantly improve function and quality of life and reduce pain. THA has yielded excellent results when assessed at 5 to 7 years after the procedure. Despite these successes, there is still ongoing debate about how certain factors relating to patients, implants, surgeons, procedures, and volume affect THA outcomes. The contribution of each of these types of factors is difficult to evaluate independently. The FDA recently provided guidance for the enrollment of women and for conducting sex-specific analyses in device studies, with an emphasis on transparency. “This is an important issue in orthopedics,” explains Monti Khatod, MD. Sex differences in THA are substantial, and industry has already started developing sex-specific devices. Furthermore, THA is more often performed in women than men. Sex-specific risk factors and outcomes have been investigated for most other major surgical procedures, but Dr. Khatod says it is even more important to understand these differences in THA, especially with the location of the femoral head center, size and shape of the femoral canal, and trabecular patterns. “It’s still unclear how anatomical sex differences can influence functional outcomes and implant survivorship,” he says. “While some studies suggest that men have higher perioperative complication and failure rates, others have observed similar failure rates and functional outcomes among men and women.” Taking a Closer Look At Joint Replacement In a study published in JAMA Internal Medicine, Dr. Khatod and colleagues used a large total joint replacement registry cohort of elective primary THA in 46 hospitals within the United States. The purpose of the analysis was to determine whether sex was associated...
Using Social Media in Oncology

Using Social Media in Oncology

The increasing popularity and use of social media in medicine offers great opportunities for healthcare professionals and their institutions to interact with patients and colleagues at a pace that has never before been possible. For oncologists, the variety of web-based and mobile technologies that make up social media allow for patient education and authoritative health messaging. Professional development and knowledge sharing, as well as increased direct patient interaction, are other attributes of these technologies. However, while social media offers great potential in healthcare, oncologists must be aware of the possible legal and privacy issues that come along with its use. The Value of Social Media According to Don S. Dizon, MD, FACP, the immediate past-chair and member of the Integrated Media and Technology Committee from the American Society of Clinical Oncology (ASCO), social media lends itself specifically to oncology for the very reason that the field appears to be evolving quickly. “Determining the social media outlets that present the most benefit to oncologists depends on each practitioner’s needs,” he says (Table 1). Twitter appears to hold significant value for oncologists, explains Dr. Dizon, who was also the lead author of an article published in the Journal of Oncology Practice that provides clinicians with guidance on using social media in oncology. “This is primarily because users have the ability to preselect individuals to follow to suit their own specific needs,” he says. “Users can also create lists to further streamline tweeted content. I have separate lists for people who tweet about their experiences with cancer, cancer centers, news disseminators, and colleagues.” Dr. Dizon adds that one of the best uses...

CHEST 2013: Peak Expiratory Flow Detects Impairment in Pulmonary Tuberculosis

The Particulars: Research shows that tuberculosis can cause frequent pulmonary impairment. However, pulmonary function testing had not been included in tuberculosis treatment guidelines until recently. Few studies have explored the usefulness of peak expiratory flow (PEF) in predicting pulmonary impairment in this patient population. Data Breakdown: In a study, 317 patients with pulmonary tuberculosis underwent spirometry and bodyplethysmography to test pulmonary function. Of these patients, 55.8% had some level of pulmonary impairment, including 16.1% with airflow restriction, 43.8% with airflow obstruction, and 37.2% with low lung function. When a predicted value of PEF less than 70% was used as the cut-off for low lung function, PEF had a sensitivity of 80.5%, specificity of 88.4%, positive predictive value of 80.5%, and negative predictive value of 88.4%. Take Home Pearl: Mechanical PEF appears to be a reliable measure for detecting pulmonary impairment in patients with pulmonary...

CHEST 2013: Comparing Endobronchial Ultrasound Scope Approaches

The Particulars: Previous studies have shown that use of an endobronchial ultrasound (EBUS) scope in the esophagus (EUS-B) provides access to areas inaccessible via the bronchial tree. Research has yet to determine if there are differences in post-procedural recovery between EBUS and EUS-B performed with an EBUS scope. Data Breakdown: A database review of patients undergoing either EBUS or EUS-B found the following:   EUS-B EBUS Maximal procedural oxygen flow 4.5 L 6.3 L Average sedation (midazolam) 2.8 mg 4.97 mg Average sedation (fentanyl) 64.22 mcg 103.94 mcg Minutes to wean off oxygen 17.5 minutes 22.5 minutes Minutes to meet respiratory discharge criteria 39.96 minutes 53.21 minutes Take Home Pearls: EUS-B appears to require less sedation and oxygen support than EBUS. EUS-B also appears to be associated with shorter recovery...

CHEST 2013: Assessing a Brief Pulmonary Rehabilitation Program for COPD

The Particulars: Studies have suggested that a brief pulmonary rehabilitation program may improve outcomes in patients with COPD. Few studies have evaluated the efficacy of such programs. Data Breakdown: For a study, COPD patients were randomized to standard medical treatment or a 6-week outpatient pulmonary rehabilitation program. The program included 1 hour of education and 2 hours of endurance and strengthening exercise and walking spread over two clinic visits per week. Intervention patients also were prescribed 2 days per week of exercises to be completed at home. No changes in pulmonary function parameters were seen in either group at 6 weeks. However, significant improvements were seen in 6-minute walking distance, quality of life (QOL), and dyspnea level in those patients participating in the rehabilitation group. Take Home Pearl: A 6-week pulmonary rehabilitation program appears to improve QOL, dyspnea, and exercise capacity in patients with...

CHEST 2013: Cigarette Size & Lung Cancer Risk

The Particulars: The significant risks of smoking have been well established for decades. Little is known, however, regarding the health risks associated with different sizes of cigarettes. Data Breakdown: Researchers at Harvard University compared urine tests among smokers of regular, king-sized, long, or ultra-long cigarettes. Smokers of long or ultra-long cigarettes had significantly higher levels to tobacco-specific carcinogens in their urine than other smokers. The elderly, African Americans, and women were more likely to smoke long or ultra-long cigarettes than other smokers. Take Home Pearls: People who smoke long or ultra-long cigarettes appear to be at greater risk of developing cancer than smokers of regular or king-size cigarettes. Efforts to increase awareness of this added risk should be targeted toward older, African-American, and female...

CHEST 2013: Yoga Beneficial in Patients With COPD

The Particulars: Yoga is a simple, inexpensive exercise method that focuses on physical postures, breathing techniques, relaxation, and “cleansing.” The role of yoga therapy in the treatment of patients with COPD is not clear. Data Breakdown: For a study, patients with stable COPD were taught yoga exercises by an instructor for 4 weeks and then continued exercising at home for 8 weeks. Lung function, severity of dyspnea, quality of life (QOL), and serum inflammatory markers were measured at baseline and at 12 weeks. Significant improvements were seen in all measured parameters for those taking part in the yoga therapy program. Take Home Pearl: Patients with stable COPD who participate in a 12-week yoga therapy program appear to achieve significant improvements in pulmonary function and...

CHEST 2013: Transthoracic Chest Ultrasound for ARF

The Particulars: Chest ultrasound is often utilized in patients with clinically suspected pulmonary disease resulting from acute respiratory failure (ARF). Few analyses have explored the accuracy of this approach. Data Breakdown: Study investigators compared chest ultrasound results with final diagnoses based on laboratory, chest radiography, and/or CT scans among patients with ARF. Chest ultrasound had strong sensitivity and specificity for detecting pulmonary edema, COPD, asthma, pneumonia, pulmonary embolism, and pneumothorax. Chest ultrasound results correlated with final diagnoses in 90% of all cases in the study. Take Home Pearl: Chest ultrasound appears to be a simple, non-invasive tool that can rapidly and reliably diagnose health conditions at the bedside in critically ill respiratory patients with...

CHEST 2013: Predicting Neurologic Outcomes After Induced Hypothermia

The Particulars: Previous studies have shown that induced hypothermia (IH) helps improve neurologic outcomes in patients after they experience a cardiac arrest. Few studies have looked at clinical predictors of neurologic outcomes of IH in this patient population. Data Breakdown: Researchers conducted a study that involved patients who survived 24 hours after IH for cardiac arrest. Of these patients, 41% attained a good neurologic outcome after IH. No significant predictors of mortality were found. However, underlying COPD, diabetes, and seizures were associated with poor neurologic outcomes. Take Home Pearls: Many patients who undergo IH after a cardiac arrest appear to achieve good neurologic outcomes. Underlying COPD, diabetes, and seizures appear to predict poor neurologic outcomes in patients who undergo IH following cardiac...

CHEST 2013: Hypotension in ED Sepsis Patients

The Particulars: The ability to predict hypotension among patients with severe sepsis or septic shock who are normotensive at ED triage may allow for more expeditious and appropriate treatment. The incidence and predictors of hypotension among this patient population have not been established in studies. Data Breakdown: In an investigation of patients presenting to an ED with severe sepsis or septic shock and normal blood pressure (BP), 64.1% developed hypotension while in the ED. The average time from initial vital sign measurement to hypotension was 152.8 minutes. Patients who developed hypotension had lower initial mean arterial pressure levels and absolute neutrophil counts than those who did not. The authors noted, however, that there were no significant differences between groups in multiple measurements. Take Home Pearls: Among patients with severe sepsis or septic shock who have normal BP at ED triage, about two-thirds appear to become hypotensive while still in the ED. This patient population may benefit from frequent BP...

CHEST 2013: Ultrasound Tops Other Diagnostics in ICU Care

The Particulars: Few studies have compared the safety and effectiveness of ultrasound with CT and x-ray imaging in clinical research involving care in ICUs. Data Breakdown: Data from two ICUs—one using ultrasound as the standard of care for diagnosis and the other using conventional imaging, such as CT scans and x-rays—were compared for a study. There were fewer x-rays performed per patient stay in the ICU unit using ultrasound as the standard of care. This ICU also had fewer CT scans per patient stay when compared with the ICU using conventional imaging as the standard of care. Mortality rates did not differ greatly between the ICUs in the analysis. Take Home Pearl: Use of ultrasound for imaging in the ICU appears to reduce patient radiation exposure without negatively affecting patient health when compared with CT or x-ray...

CHEST 2013: Electronic ICUs Provide Remote Care

The Particulars: Hospitals in the United States are increasingly using electronic ICUs (eICUs) to provide supplemental care with around-the-clock monitoring. With eICUs, patients are managed by providers using two-way cameras, video monitors, microphones, and alarms in a remote location. Few studies have examined the effect on clinical outcomes of ICUs as a supplementary remote intensive care program. Data Breakdown: For a study, researchers compared the rate of falls, mortalities, incidence of code blues, and length of stay (LOS) between ICU patients seen with and without use of an eICU at a remote hospital. The following was observed:   With eICU (n=1,227) Without eICU (n=1,310) Number of code blues 39 54 Number of falls 0 1 Number of overall mortalities 77 90 LOS 3 days 3.1 days Take Home Pearls: The incidence of code blues, falls, and overall mortality appear to be similar among ICU patients treated with normal care and eICU care. LOS also appears to be similar in patients treated with and without...

Is Pain Really The 5th Vital Sign?

This has been bothering me for many years. No, pain is not the 5th vital sign. It’s not a sign at all. Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature. What do those four signs have in common? They can be measured. A sign is defined as something that can be measured. On the other hand, pain is subjective. It can be felt by a patient. Despite efforts to quantify it with numbers and scales using smiley and frown faces, it is highly subjective. Pain is a symptom. Pain is not a vital sign, nor is it a disease. How did pain come to be known as the 5th vital sign? The concept originated in the VA hospital system in the late 1990s and became a Joint Commission standard in 2001. Pain was allegedly being under treated. Hospitals were forced to emphasize the assessment of pain for all patients on every shift with the (mistaken) idea that all pain must be closely monitored and treated . This is based on the (mistaken) idea that pain medication is capable of rendering patients completely pain free. This has now become an expectation of many patients who are incredulous and disappointed when that expectation is not met. Talk about unintended consequences. The emphasis on pain, pain, pain has resulted in the following: Diseases have been discovered that have no signs and with pain as the only symptom. Pain management clinics have sprung up all over the place. In 2010, 16,665 people died from opioid-related overdoses. That is a four-fold increase from 1999 when only 4,030 such deaths occurred....
TCT 2013

TCT 2013

New research is being presented at TCT 2013, the 25th anniversary of the Transcatheter Cardiovascular Therapeutics annual meeting, from October 27 to November 1, in San Francisco. Meeting Highlights The Effects of Intraprocedural Stent Thrombosis Hydration Choice Matters for Coronary Angiography Radial Access PCI Beneficial in Women   News From the Meeting Second Generation Transcatheter Aortic Valve Shown to Successfully Address Complications of TAVR New Study Evaluates Outcomes of Providing Access to Platelet Function Testing in a Clinical Setting Removing Blood Clots During PCI Does Not Improve Outcomes Compared With Standard Angioplasty in Patients With NSTEMI “Hybrid Procedure” Combining Minimally Invasive CABG With PCI Is Feasible and Safe Compared With Traditional CABG Genetic Profiling may Provide Clinical Benefit by Identifying Heart Attack Patients Who Are Resistant to Blood Thinners Study Examines the Impact of Insulin Treatment Status in Diabetic Patients With Multivessel Coronary Artery Disease New Study Demonstrates Potential Benefits of Shorter-Term Dual Antiplatelet Therapy in Patients Treated With Second Generation Drug-Eluting Stent Comparison of Two Third-Generation Drug-Eluting Stents Establishes Comparable Safety and Efficacy; Demonstrates Non-Inferiotrity of Newest Zotarolimus-Eluting Stent Therapeutic Hypothermia Is Safe and Feasible as Adjunctive Care for Heart Attack Patients New Study Compares Conservative and Aggressive Revascularization Strategies for Coronary Stenting Based Upon Angiography Alone Trial Examines Benefits of Using a New Test to Determine the Severity of Coronary Artery Disease Good Outcomes With Both Drug-Eluting Stents and Drug-Eluting Balloons in Treating Patietns With Bare Metal Stent Restenosis Study Demonstrates High Accuracy of Non-Invasive Computed FFR in Evaluating Patients With Coronary Artery Disease New Study Examines Safety and Efficacy of Drug-Coated Ballon Angioplasty for Treatmetn of...
Updated Guidelines for Heart Failure

Updated Guidelines for Heart Failure

Recently, the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) jointly released an expanded clinical practice guideline for the management of patients with heart failure (HF). The update, published in the Journal of the American College of Cardiology was designed to assist clinicians in selecting the best management strategies for patients. “The guideline updates definitions and classifications for HF, increases the emphasis on patient-centric outcomes, and introduces ‘guideline- directed medical therapy’ (GDMT),” explains Clyde W. Yancy, MD, MSc, FACC, who chaired the ACCF/AHA writing committee. Descriptions & Classifications of Heart Failure The ACCF/AHA guideline update provides a more focused approach on dilated cardiomyopathies and the appropriate evaluation of patients. This includes family and genetic screening and counseling. “The guidelines once again endorse four stages of disease progression: Stages A thru D,” explains Dr. Yancy. “Stage A patients are those with positive risk factors, whereas Stage B patients have existing but still asymptomatic left ventricular function.” “The expectations are highest for hospitalized patients with HF because of their vast resource consumption from initial admissions to subsequent readmissions.” Stage C is the classic patient with congestive HF, but importantly, Dr. Yancy says this patient group is now well dichotomized as having HF with reduced ejection fraction (EF) or HF with preserved EF. “Best therapies are aligned with each stage, specifically risk factor modification, pre-emptive medical and device therapies for asymptomatic left ventricular dysfunction, and classic evidence-based therapies for symptomatic HF patients with reduced EF,” he says. “The guidelines also provide a treatment algorithm for Stage C HF patients with reduced EF [Figure]. The algorithm, known as GDMT, can...
Women & Diabetes: A Call to Action

Women & Diabetes: A Call to Action

Nearly half of all adults with diabetes in the United States are women, and the risk of cardiovascular disease (CVD)—the most common complication of diabetes—is more serious among women than men. Recent reports suggest that gender disparities exist in terms of access to care and receipt of preventive services (Table 1). Among people with diabetes who have had a heart attack, women have lower survival rates and a poorer quality of life than men. “It’s important to identify women with diabetes and those at high risk for the disease so that we can provide the necessary interventions to improve outcomes,” says Elizabeth Barrett-Connor, MD, FACP, FAHA. Early interventions and access to preventive care services are important for reducing diabetes risk as well as risks for developing other diseases, most importantly CVD. A Paucity of Data on CVD & Women About 40 years ago, few cohort studies of CVD included women, and fewer still included diabetes or glycemia as risk factors. In 1985, a review of hyperglycemia as a risk factor for coronary heart disease (CHD) was published. It included 29 prospective studies of glycemia and heart disease risk, adjusting for cholesterol, smoking, and blood pressure. It found an independent association between hyperglycemia and CHD in five of 13 cohort studies. Glycemia was not associated with CVD outcomes in studies using fasting plasma glucose or casual glucose levels. “Alarmingly, only four of these 29 studies included women,” says Dr. Barrett-Connor. “Another study, published in 1999, reviewed glucose and incident cardiovascular events, but of the 20 studies that were analyzed, only two included women. These large analyses highlight the fact that...
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