Day: 02/07/2012

Universal screening for type 2 diabetes .

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From time to time I am asked about universal versus selective screening for type 2 diabetes.  The logic for universal screening goes something like: “The prevalence of diabetes is increasing by epidemic proportions.  We have increasingly been able to show that treatment of diabetes and its associated cardiovascular risk factors can prevent future vascular disease.  Even in developed societies 20-30% of people with diabetes are undiagnosed.  Wouldn’t we be better off identifying persons with diabetes?”

There are several ways to approach this issue.  First let’s look at the issues of universal screening versus selective screening from a cost-effectiveness perspective.  We have finite resources. How can we best spend them?  An example of this approach was published in the Annals of Internal Medicine, in a study called Screening for Type 2 Diabetes Mellitus: A Cost-Effectiveness Analysis, which concluded that ”diabetes screening targeted to people with hypertension is more cost-effective than universal screening. The most cost-effective strategy is targeted screening at age 55 to 75 years.”

Based on this and similar studies the US Preventative Services Task Force recommended screening in the presence of hypertension or pre=hypertension (blood pressure equal to or greater that 135/80 mm Hg), but not universal screening.

But what about all the evidence that we can prevent vascular complications by early diagnosis and aggressive treatment?  Nathan and Herman addressed that issue in an editorial in the same issue of the Annals.  They concluded that taking into account the prevention of complications universal screening becomes cost-effective.  However, this conclusion assumes nearly ideal preventative treatment of diabetes and its cardiovascular risk factors at diagnosis.  They therefore tempered their advocacy of universal screening as follows:

“Unfortunately, the current state of delivery of care to persons with diagnosed diabetes in the United States does not bode well for the treatment of patients identified through screening. Many published “report cards” of diabetes care have shown that the treatment of glycemia, hypertension, and dyslipidemia and surveillance of foot and eye complications occur at far below recommended levels (20). Unless we optimize care after we diagnose diabetes, screening cannot be effective or cost-effective.”(Annals of Internal Medicine May 4, 2004, 140:756-758)

This conclusion was based upon the paper A Diabetes Report Card for the United States: Quality of Care in the 1990s, which concluded that “according to U.S. data collected during 1988–1995, a gap exists between recommended diabetes care and the care patients actually receive. These data offer a benchmark for monitoring changes in diabetes care.”

There has been no compelling evidence since this study was published to suggest that we are treating diabetes and its cardiovascular risk factors better today than in 2002. I conclude that the CDC’s recommendations for screening make the most clinical and scientific sense. They are based upon a technical review cited below:

“Based on the results of this study, opportunistic screening can be considered by health care delivery systems. However, screening outside the clinic setting is not warranted. It is also noted that people with symptoms of diabetes and those who have clinical signs and symptoms of diabetes should be tested and diagnosed. When people have signs or symptoms that suggest diabetes, clinicians should maintain a high index of suspicion and pursue diagnostic testing. This activity is considered to be an appropriate diagnostic effort and shows good clinical care. Screening only applies to people who are truly asymptomatic.”

Universal screening does not make sense in our imperfect world.  Screening in clinical settings is the most cost-effective approach. Age, weight, family and personal history and the presence of other cardiovascular risk factors should be taken into consideration.

Source:  BMJ blog

Feasibility of home-based functional electrical stimulation cycling: case report.

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To determine the feasibility of a home-based FES-LEC (functional electrical stimulation lower extremities cycling) program and effects on body composition, quality of life (QOL) and seat pressure mapping in an older individual with spinal cord injured (SCI).

Setting:

Home-based FES-LEC with internet connection. Southeastern United States.

Methods:

FES-LEC three sessions per week for 9 weeks in the participant’s home and monitored by the research staff via internet connection. Pre- and post-exercise program testing of seat pressure mapping, QOL and body composition including percent body fat (%BF), fat mass (FM), lean mass (LM) and bone mineral density (BMD).

Results:

The participant completed 25 of 27 recommended exercise sessions over 9 weeks for a 93% compliance rate. Cycling distance increased from 3.98 to 9.00 km (126%). Total body LM increased from 48.94 to 53.02 kg (8.3%). The %BF decreased from 29.6 to 28.4(−1.2%). Total body weight, FM and BMD remained unchanged. Average static seat pressure decreased from 55.5 to 52.59 mm Hg (5%), whereas maximum seat pressure decreased from 120.76 to 91.5 mm Hg (24%). The psychological domain (perception of body image, appearance and self-esteem) of the QOL questionnaire improved from 12.67 to 14.

Conclusion:

 

Positive changes in this study regarding body composition, QOL and seat pressure mapping support results of clinical studies using FES-LEC training on younger adults with SCI. The high percentage of exercise adherence and positive results on body composition, QOL and seat pressure provide support for the feasibility of home-based FES-LEC.

Source: Spinal Cord

 

social support; social skills; spinal cord injury.

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The role of social support and social skills in people with spinal cord injury—a systematic review of the literature

To examine the current knowledge of how social support and social skills are associated with aspects of health, functioning and quality of life of persons living with spinal cord injury (SCI).

Methods:

A systematic literature review was conducted. The literature search was carried out in Pubmed, PsycINFO, ERIC (Educational Resources Information Centre), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase and SSCI (Social Sciences Citation Index). Publications were identified according to predefined eligibility criteria; study qualities were evaluated, study results extracted and a narrative synthesis was compiled.

Results:

In all, 58 publications about social support and SCI were included. Social support was positively related to physical and mental health, pain, coping, adjustment and life satisfaction. Social skills were assessed in 11 studies: social problem solving (n=7), assertiveness (n=3), verbal communication (n=1) and self-monitoring (n=1) were examined. Effective problem-solving skills were related to better mental health outcomes, health prevention behavior and less secondary conditions. Assertiveness was related to higher depression in rehabilitation setting. Interventions targeted at social support or social skills were scarcely studied. Only one study examined the relationship between social skills and social support in SCI.

Conclusion:

Social support is associated with better health and functioning in individuals with SCI. However, the full range of social skills has not yet been studied in people with SCI. Furthermore, the role of social skills in relation to social support, health and functioning remains unclear. Better understanding of social skills and social support in SCI could facilitate the development of targeted and effective interventions to enhance functioning of people with SCI.

Source: Spinal Cord.

Management of acute overdose or withdrawal state in intrathecal baclofen therapy.

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Individuals who are treated with intrathecal Baclofen (ITB) pump delivery system for intractable spasticity can suffer from severe morbidity as a result of acute overdose or withdrawal of ITB, which can also be life threatening. Current literature has a number of single case studies with different approaches to the management in such states.

Objectives:

The aim of this article is to consolidate available evidence and develop treatment pathways for acute ITB overdose and withdrawal states.

Methods:

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases using the keywords ‘intrathecal’, ‘baclofen’, ‘withdrawal’, ‘overdose’ to identify studies (published up to December 2010) that focused on presentation or treatment of acute overdose and withdrawal state in ITB therapy. Only original articles in English involving adult population were included.

Results:

Initial search revealed 130 articles. After reading the abstract, 13 studies on ITB overdose and 23 studies on ITB withdrawal were deemed suitable for inclusion. All studies were either single-case studies or case series.

Conclusion:

Acute ITB overdose is managed with immediate cessation of baclofen delivery through the system, reducing the baclofen load by cerebrospinal fluid aspiration and by providing supportive treatment in an intensive care setting. There is no specific antidote for reversing overdose symptoms. Acute ITB withdrawal is managed by restoring the delivery of ITB, providing supportive care in an intensive care setting and using drugs like low dose propofol or benzodiazepines in selected cases. Early involvement of ITB physicians is strongly recommended.

Source:Spinal  Cord

Regulation of Rev1 by the Fanconi anemia core complex.

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The 15 known Fanconi anemia proteins cooperate in a pathway that regulates DNA interstrand cross-link repair. Recent studies indicate that the Fanconi anemia pathway also controls Rev1-mediated translesion DNA synthesis (TLS). We identified Fanconi anemia–associated protein (FAAP20), an integral subunit of the multisubunit Fanconi anemia core complex. FAAP20 binds to FANCA subunit and is required for stability of the complex and monoubiquitination of FANCD2. FAAP20 contains a ubiquitin-binding zinc finger 4 domain and binds to the monoubiquitinated form of Rev1. FAAP20 binding stabilizes Rev1 nuclear foci and promotes interaction of the Fanconi anemia core with PCNA–Rev1 DNA damage bypass complexes. FAAP20 therefore provides a critical link between the Fanconi anemia pathway and TLS polymerase activity. We propose that the Fanconi anemia core complex regulates cross-link repair by channeling lesions to damage bypass pathways and preventing large DNA insertions and deletions.

Source:  Nature Structural & Molecular Biology.

Obesity, Physical Inactivity, and Colonic Diverticular Disease Requiring Hospitalization in Women: A Prospective Cohort Study

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Lifestyle factors other than dietary fiber intake and risk for colonic diverticular disease have only been examined in few studies. The objective of this study was to investigate the association between obesity and physical inactivity and diverticular disease in a population-based cohort of women.

METHODS:

This was a prospective population-based cohort study. In all, 36,592 women, born 1914–1948, in the Swedish Mammography Cohort were followed 1997–2009. Body mass index (BMI; kg/m2), physical activity, diet, smoking, and other lifestyle factors were collected at baseline through questionnaires. Cases of diverticular disease were identified from the Swedish Patient and Death Registers. Relative risks (RRs) of diverticular disease requiring hospitalization (or being the cause of death) according to BMI and physical activity were estimated using Cox proportional hazards models. The multivariable models were adjusted for age; intake of dietary fiber; diabetes; hypertension; use of acetylsalicylate acid, non-steroid anti-inflammatory drug, or steroid medication; alcohol consumption; smoking; and educational level.

RESULTS:

During 12 years, 626 cases of incident diverticular disease requiring hospitalization were found. Two women were registered in the National Death Register only. In multivariable analysis, women with BMI 25–29.99 had 29% increased risk (RR=1.29; 95% confidence interval (CI): 1.08, 1.54) and obese women (BMI≥30) had 33% (1.33; 95% CI: 1.03–1.72) increased risk of diverticular disease compared to women with BMI 20–24.99. Exercise ≤30 min/day increased the risk for disease with 42% (1.42; 95% CI: 1.18–1.69) compared with exercise >30 min/day in multivariable analysis. Ninety-eight subjects were hospitalized due to complications; perforation or abscess. Women with BMI≥30 had a twofold (RR=2.00; 95% CI: 1.08–3.73; P=0.028) increased risk for complicated disease.

CONCLUSIONS:

Overweight, obesity, and physical inactivity among women increase diverticular disease requiring hospitalization

Source: American Journal of Gastroenterology.

 

 

Abnormal Immune Regulation and Low-Grade Inflammation in IBS: Does One Size Fit All?

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Evidences suggest that there is low-grade inflammation in the colonic mucosa and/or a state of immune activation in patients with irritable bowel syndrome (IBS). Results from available studies are inconsistent mainly because of differences in measures, methodologies and study populations. In this issue, Chang et al. evaluated a comprehensive set of cytokines, immune markers and immune-related cells in patients with non post infectious IBS (non PI-IBS) and controls. The main finding was a lower expression of the mRNA of the anti-inflammatory IL-10 cytokine in the colonic mucosa of women with non PI-IBS without any differences in the cell counts. These results suggest that in non PI-IBS, there is altered immune regulation/activation without evidence of low-grade mucosal inflammation. Further, PI and non PI-IBS may be associated with different alterations in immune function/activation.

Source: American Journal of Gastroenterology.

 

Serum and Colonic Mucosal Immune Markers in Irritable Bowel Syndrome.

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Low-grade colonic mucosal inflammation has been postulated to have an important role in the pathophysiology of irritable bowel syndrome (IBS). The objectives of this study were (i) to identify serum and tissue-based immunological and neuroendocrine markers associated with mucosal inflammation in male (M) and female (F) patients with non-post-infectious IBS (non-PI-IBS) compared with healthy controls and (ii) to assess possible correlations of such markers with IBS symptoms.

METHODS:

Sigmoid mucosal biopsies were obtained from 45 Rome II positive IBS patients without a history of PI-IBS (26 F, 35.5% IBS-C, 33.3% IBS-D, 31.1% IBS-A/M) and 41 healthy controls (22 F) in order to measure immunological markers (serum cytokine levels, colonic mucosal mRNA levels of cytokines, mucosal immune cell counts) and neuroendocrine markers associated with mucosal inflammation (corticotropin releasing factor- and neurokinin (NK)-related ligands and receptors, enterochromaffin cells). Symptoms were measured using validated questionnaires.

RESULTS:

Of all the serum and mucosal cytokines measured, only interleukin-10 (IL-10) mRNA expression showed a group difference, with female, but not male, patients showing lower levels compared with female controls (18.0±2.9 vs. 29.5±4.0, P=0.006). Mucosal mRNA expression of NK-1 receptor was significantly lower (1.15±0.19 vs. 2.66±0.56, P=0.008) in female, but not male, patients compared with healthy controls. No other significant differences were observed.

CONCLUSIONS:

Immune cell counts and levels of cytokines and neuropeptides that are associated with inflammation were not significantly elevated in the colonic mucosa of non-PI-IBS patients, and did not correlate with symptoms. Thus, these findings do not support that colonic mucosal inflammation consistently has a primary role in these patients. However, the finding of decreased IL-10 mRNA expression may be a possible biomarker of IBS and warrants further investigation.

Source: American Journal of Gastroenterology.

 

Hospital Readmissions Among Patients With Decompensated Cirrhosis.

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Early rehospitalizations have been well characterized in many disease states, but not among patients with cirrhosis. The aims of this study were to identify the frequency, costs, predictors, and preventable causes of hospital readmissions among patients with decompensated cirrhosis.

METHODS:

Rates of readmission were calculated for 402 patients discharged after one of the following complications of cirrhosis: ascites, spontaneous bacterial peritonitis, renal failure, hepatic encephalopathy, or variceal hemorrhage. Costs of readmissions were calculated using the hospital accounting system. Predictors of time to first readmission were determined using Cox regression, and predictors of hospitalization rate/person-years were determined using negative binomial regression. The independent association between readmission rate and mortality was determined using Cox regression. Admissions within 30 days of discharge were assessed by two reviewers to determine if preventable.

RESULTS:

Overall, 276 (69%) subjects had at least one nonelective readmission, with a median time to first readmission of 67 days. By 1 week after discharge, 14% of subjects had been readmitted, and 37% were readmitted within 1 month. The mean costs for readmissions within 1 week and between weeks 1 and 4 were $28,898 and $20,581, respectively. During a median follow-up of 203 days, the median number of readmissions was 2 (range 0–40), with an overall rate of 3 hospitalizations/person-years. Patients with more frequent readmissions had higher risk of subsequent mortality, despite adjustment for confounders including the Model for End-stage Liver Disease (MELD) score. Predictors of time to first readmission included MELD score, serum sodium, and number of medications on discharge; predictors of hospitalization rate included these variables as well as the number of cirrhosis complications and being on the transplant list at discharge. Among 165 readmissions within 30 days, 22% were possibly preventable.

CONCLUSIONS:

Hospital readmissions among patients with decompensated cirrhosis are common, costly, moderately predictable, in some cases, possibly preventable, and independently associated with mortality. These findings support the development of disease management interventions to prevent rehospitalization.

Source: American Journal of Gastroenterology.

Long-Term Outcome of Patients Treated With Double Balloon Enteroscopy for Small Bowel Vascular Lesions.

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Early rebleeding rate after endoscopic therapy with double balloon enteroscopy (DBE) of hemorrhagic small bowel vascular lesions (SBVL) varies between 10 and 50%. In recent reports, long-term follow-up of patients have been described but rebleeding risk factors are still not well established. The aim of the current study was to identify long-term treatment success rate and rebleeding risk factors after DBE therapy in a large cohort.

METHODS:

We conducted a single-center, retrospective cohort study in a large French tertiary-referral center between January 2004 and December 2007.

RESULTS:

Among 261 patients presenting with obscure gastrointestinal bleeding (OGIB), SBVL was present in 133 patients and was treated successfully in 129 (97%) using mainly argon plasma coagulation. Ninety-eight patients were followed up for a mean period of 22.6±13.9 months (range 1–52). Rebleeding rate was 46% (45/98 patients) at 36 months. On multivariate analysis, the total number of observed lesions (hazard ratio (HR): 1.15, 95% confidence interval (CI): 1.06–1.25, P=0.001) and the presence of a valvular and/or arrhythmic cardiac disease (HR: 2.50, 95% CI: 1.29–4.87, P=0.007) were significantly associated with the risk of rebleeding. Complication rate of therapeutic DBE was 2.3% with no mortality.

CONCLUSIONS:

 

Endoscopic therapy using DBE for SBVL in patients with recurrent OGIB allows a long-term remission in more than half of the patients. Independent rebleeding risk factors after a first endoscopic therapy are an increased number of SBVL and an associated valvular/arrhythmic heart disease.

Source: American Journal of Gastroenterology.