viernes, 17 de agosto de 2012
Simultaneous Control of Diabetes Mellitus, Hypertension, and Hyperlipidemia in 2 Health Systems
- Emily B. Schroeder, MD, PhD,
- Rebecca Hanratty, MD,
- Brenda L. Beaty, MSPH,
- Elizabeth A. Bayliss, MD, MSPH,
- Edward P. Havranek, MD and
- John F. Steiner, MD, MPH
+ Author Affiliations: From the Institute for Health Research, Kaiser Permanente Colorado, Denver (E.B.S., E.A.B., J.F.S.); Department of Medicine, University of Colorado Denver (E.B.S.); Denver Health, Denver, CO (R.H., E.P.H.); Colorado Health Outcomes Program, University of Colorado Denver (B.L.B.); and Department of Family Medicine, University of Colorado Denver (E.A.B.). Correspondence to Emily B. Schroeder, MD, PhD, Institute for Health Research, Kaiser Permanente Colorado, PO Box 378066, Denver, CO 80237-8066. E-mail emily.x.schroeder@kp.org
Abstract
Background—Many individuals with diabetes mellitus, hypertension, and hyperlipidemia have difficulty achieving control of all 3 conditions. We assessed the incidence and duration of simultaneous control of hyperglycemia, blood pressure, and low-density lipoprotein cholesterol in patients from 2 health care systems in Colorado.
Methods and Results—We performed a retrospective cohort study of adults at Denver Health and Kaiser Permanente Colorado with diabetes mellitus, hypertension, and hyperlipidemia from 2000 through 2008. Over a median of 4.0 and 4.4 years, 16% and 30% of individuals at Denver Health and Kaiser Permanente achieved the primary outcome (simultaneous control with a glycosylated hemoglobin (HbA1c) <7 .0=".0" and="and" ba="ba" blood="blood" cholesterol="cholesterol" dl="dl" goals="goals" hg="hg" less="less" lipoprotein="lipoprotein" low-density="low-density" mg="mg" mm="mm" pressure="pressure" respectively.="respectively." strict="strict" sub="sub" with="with">1c
Conclusions—Simultaneous control of diabetes mellitus, hypertension, and hyperlipidemia was uncommon and generally transient. Less stringent goals had a relatively large effect on the proportion achieving simultaneous control. Individuals who simultaneously achieve multiple treatment goals may provide insight into self-care strategies for individuals with comorbid health conditions.
martes, 14 de agosto de 2012
Statin Benefits Offset Diabetes Risk
The cardiovascular benefits of statin treatment for primary prevention outweighed the risk of developing diabetes, even among those at risk for the condition, an analysis of the JUPITER trial showed.
Taking into account several outcomes, statin therapy prevented 134 cardiovascular events or deaths for every 54 cases of new-onset diabetes among participants with at least one risk factor for diabetes, Paul Ridker, MD, of Brigham and Women's Hospital in Boston, and colleagues determined.
And among those who were not at risk for developing diabetes, statin therapy prevented 86 cardiovascular events or deaths with no additional cases of new-onset diabetes, the researchers reported in the Aug. 11 issue of The Lancet.
"As the increase in risk of diabetes associated with statin therapy seems limited to patients with major risk factors for diabetes, monitoring of glucose concentrations when starting statin therapy might not be needed in those who have normal pretreatment glucose concentrations or who do not have multiple characteristics of metabolic syndrome," Ridker and colleagues wrote.
"For our patients, we hope these data ease concern about risks associated with statin therapy when these drugs are appropriately prescribed for cardiovascular risk reduction as an adjunct to dietary discretion, increased exercise, and smoking cessation."
Trial data and meta-analyses have indicated that statins increase the risk of developing diabetes, possibly in a dose-response fashion. In the JUPITER trial, for example, patients taking rosuvastatin (Crestor) had a 27% increased risk of new-onset diabetes compared with those taking placebo.
And earlier this year, the FDA added a warning about the diabetes risk to all statin labels. There remains some concern that when statins are used for primary prevention, the cardiovascular benefits may not outweigh the diabetes risk.
To explore the issue, Ridker and colleagues examined data from 17,603 participants in the JUPITER trial. All were free from previous cardiovascular disease and diabetes at baseline. The main study results showed that rosuvastatin reduced the rate of MI, stroke, hospitalization for unstable angina, arterial revascularization, or cardiovascular death by a relative 44%.
In the current analysis, the researchers divided the participants into two groups -- those with at least one of four major risk factors for diabetes (metabolic syndrome, impaired fasting glucose, obesity, or a glycated hemoglobin greater than 6%) and those with none of those risk factors.
Most of the patients (63%) had at least one of the risk factors and, as expected, they were more likely to develop diabetes during the study (rate of 1.88 versus 0.18 per 100 person-years).
Overall, the risk of diabetes was greater in the rosuvastatin group (HR 1.25, 95% CI 1.05 to 1.49), a relationship confined to those participants who were already at risk for developing the disease. The average time from randomization to diagnosis of diabetes was shorter in the statin group (84.3 versus 89.7 weeks).
Among those at risk for diabetes, rosuvastatin was associated with:
- 39% reduction in the primary endpoint (HR 0.61, 95% CI 0.47 to 0.79)
- 36% reduction in venous thromboembolism (HR 0.64, 95% CI 0.39 to 1.06)
- 17% reduction in total mortality (HR 0.83, 95% CI 0.64 to 1.07)
- 28% increase in diabetes (HR 1.28, 95% CI 1.07 to 1.54)
Among those with no risk factors for diabetes, statin therapy was associated with:
- 52% reduction in the primary endpoint (HR 0.48, 95% CI 0.33 to 0.68)
- 53% reduction in venous thromboembolism (HR 0.47, 95% CI 0.21 to 1.03)
- 22% reduction in total mortality (HR 0.78, 95% CI 0.59 to 1.03)
- No increase in diabetes (HR 0.99, 95% CI 0.45 to 2.21).
Taken together, those findings indicate a net benefit for statin treatment in both groups of participants.
"A major take-home message for the clinician involved in either primary or secondary prevention of cardiovascular disease is that all individuals on a statin who have major risk factors for diabetes, particularly impaired fasting glucose, need to be informed about the risk, monitored regularly for hyperglycemia, and advised to lose weight and take regular physical exercise to mitigate the emergence of diabetes," Gerald Watts, DSc, PhD, and Esther Ooi, PhD, of the University of Western Australia in Perth, wrote in an accompanying editorial.
Ridker and colleagues noted some limitations of their analysis, including the use of a single statin at a single dose, the fact that all participants had elevated high-sensitivity C-reactive protein, and the relatively short duration of follow-up (median 2 years), which precludes a long-term assessment of the risk-benefit balance.
The JUPITER trial was an investigator-initiated project funded by AstraZeneca.
Ridker is the principal investigator of the trial and received grant support from AstraZeneca for its conduct. He has served as a consultant to Merck, ISIS, Vascular Biogenics, Boehringer Ingelheim, Abbott, and Genzyme; receives additional research grant support from Novartis; and is listed as a co-inventor on patents held by the Brigham and Women's Hospital related to inflammatory biomarkers in cardiovascular disease and diabetes that have been licensed to Siemens and AstraZeneca. His co-authors reported relationships with AstraZeneca, GlaxoSmithKline, Merck, Novartis, Pfizer, ProNova, Sigma-Tau, Athera Biotechnologies, Carolus Therapeutics, Interleukin Genetics, and BIND Biosciences.
Watts has received honoraria or lecture fees from AstraZeneca, Pfizer, Merck Sharp & Dohme, Sanofi, Amgen, Abbott, and Glaxo Wellcome. Ooi reported that she had no conflicts of interest.
Ridker is the principal investigator of the trial and received grant support from AstraZeneca for its conduct. He has served as a consultant to Merck, ISIS, Vascular Biogenics, Boehringer Ingelheim, Abbott, and Genzyme; receives additional research grant support from Novartis; and is listed as a co-inventor on patents held by the Brigham and Women's Hospital related to inflammatory biomarkers in cardiovascular disease and diabetes that have been licensed to Siemens and AstraZeneca. His co-authors reported relationships with AstraZeneca, GlaxoSmithKline, Merck, Novartis, Pfizer, ProNova, Sigma-Tau, Athera Biotechnologies, Carolus Therapeutics, Interleukin Genetics, and BIND Biosciences.
Watts has received honoraria or lecture fees from AstraZeneca, Pfizer, Merck Sharp & Dohme, Sanofi, Amgen, Abbott, and Glaxo Wellcome. Ooi reported that she had no conflicts of interest.
- AHA: JUPITER Results Point to Role of Statins for ‘Apparently Healthy’ Patients
- Triglycerides and Cardiovascular Disease
Primary source: The Lancet
Source reference:
Ridker P, et al "Cardiovascular benefits and diabetes risks of statin therapy in primary prevention: an analysis from the JUPITER trial" Lancet 2012; 380: 565-571.
Source reference:
Ridker P, et al "Cardiovascular benefits and diabetes risks of statin therapy in primary prevention: an analysis from the JUPITER trial" Lancet 2012; 380: 565-571.
lunes, 13 de agosto de 2012
The Bullying Culture of Medical School
Powerfully built and with the face of a boxer, he cast a bone-chilling shadow wherever he went in the hospital.
At least that is what my medical school classmates and I thought whenever we passed by a certain resident, or doctor-in-training, just a few years older than we were.
But one day, one of our classmates, having already been on the receiving end of several of this doctor’s tirades, shouted back. She questioned one of his conclusions in front of the rest of the medical team, insisted on getting an explanation, then screamed back when he started yelling at her.
The entire episode unnerved us all; and over the next few weeks, we marveled at her courage and fretted over her potentially ruined career prospects. But there was one aspect of the event that disturbed us even more. One classmate who had witnessed the “screaming match” described how our fellow medical student had raised her voice and positioned her body as she threatened the doctor. “It was weird,” he recounted. “It was like watching her turn into him.”
For 30 years, medical educators have known that becoming a doctor requires more than an endless array of standardized exams, long hours on the wards and years spent in training. For many medical students, verbal and physical harassment and intimidation are part of the exhausting process, too.
It was a pediatrician, a pioneer in work with abused children, who first noted the problem. And early studies found that abuse of medical students was most pronounced in the third year of medical school, when students began working one on one or in small teams with senior physicians and residents in the hospital. The first surveys found that as many as 85 percent of students felt they had been abused during their third year. They described mistreatment that ranged from being yelled at and told they were “worthless” or “the stupidest medical student,” to being threatened with bad grades or a ruined career and even getting hit, pushed or made the target of a thrown medical tool.
Nonetheless, many of these researchers believed that such mistreatment could be eliminated, or at least significantly mitigated, if each medical school acknowledged the behavior, then created institutional anti-harassment policies, grievance committees and educational, training and counseling programs to break the abuse cycle.
One medical school became a leader in adopting such changes. Starting in 1995, educators at the David Geffen School of Medicine at the University of California, Los Angeles, began instituting a series of schoolwide reforms. They adopted policies to reduce abuse and promote prevention; established a Gender and Power Abuse Committee, mandated lectures, workshops and training sessions for students, residents and faculty members; and created an office to accept confidential reports, investigate and then address allegations of mistreatment.
To gauge the effectiveness of these initiatives, the school also began asking all students at the end of their third year to complete a five-question survey on whether they felt they had been mistreated over the course of the year.
The school has just published the sobering results of the surveys over the last 13 years. While there appears to have been a slight drop in the numbers of students who report experiencing mistreatment, more than half of all medical students still said that they had been intimidated or physically or verbally harassed.
Fuente: http://well.blogs.nytimes.com/2012/08/09/the-bullying-culture-of-medical-school/?smid=tw-share
At least that is what my medical school classmates and I thought whenever we passed by a certain resident, or doctor-in-training, just a few years older than we were.
But one day, one of our classmates, having already been on the receiving end of several of this doctor’s tirades, shouted back. She questioned one of his conclusions in front of the rest of the medical team, insisted on getting an explanation, then screamed back when he started yelling at her.
The entire episode unnerved us all; and over the next few weeks, we marveled at her courage and fretted over her potentially ruined career prospects. But there was one aspect of the event that disturbed us even more. One classmate who had witnessed the “screaming match” described how our fellow medical student had raised her voice and positioned her body as she threatened the doctor. “It was weird,” he recounted. “It was like watching her turn into him.”
For 30 years, medical educators have known that becoming a doctor requires more than an endless array of standardized exams, long hours on the wards and years spent in training. For many medical students, verbal and physical harassment and intimidation are part of the exhausting process, too.
It was a pediatrician, a pioneer in work with abused children, who first noted the problem. And early studies found that abuse of medical students was most pronounced in the third year of medical school, when students began working one on one or in small teams with senior physicians and residents in the hospital. The first surveys found that as many as 85 percent of students felt they had been abused during their third year. They described mistreatment that ranged from being yelled at and told they were “worthless” or “the stupidest medical student,” to being threatened with bad grades or a ruined career and even getting hit, pushed or made the target of a thrown medical tool.
Nonetheless, many of these researchers believed that such mistreatment could be eliminated, or at least significantly mitigated, if each medical school acknowledged the behavior, then created institutional anti-harassment policies, grievance committees and educational, training and counseling programs to break the abuse cycle.
One medical school became a leader in adopting such changes. Starting in 1995, educators at the David Geffen School of Medicine at the University of California, Los Angeles, began instituting a series of schoolwide reforms. They adopted policies to reduce abuse and promote prevention; established a Gender and Power Abuse Committee, mandated lectures, workshops and training sessions for students, residents and faculty members; and created an office to accept confidential reports, investigate and then address allegations of mistreatment.
To gauge the effectiveness of these initiatives, the school also began asking all students at the end of their third year to complete a five-question survey on whether they felt they had been mistreated over the course of the year.
The school has just published the sobering results of the surveys over the last 13 years. While there appears to have been a slight drop in the numbers of students who report experiencing mistreatment, more than half of all medical students still said that they had been intimidated or physically or verbally harassed.
Fuente: http://well.blogs.nytimes.com/2012/08/09/the-bullying-culture-of-medical-school/?smid=tw-share
domingo, 5 de agosto de 2012
sábado, 4 de agosto de 2012
La primera presea olímpica para Guatemala !!!
Me llena de orgullo que una persona tan humilde y con mucha más adversidad sea nuestro heroe olímpico... Ganó plata, pero vale oro !!!
jueves, 2 de agosto de 2012
Combination Type 2 Diabetes Pill Approved in Europe
Posted: 07/27/2012
July 27, 2012 — The European Commission has approved the combination pill containing the dipeptidyl peptidase-4 inhibitor linagliptin and metformin hydrochloride for the treatment of adults with type 2 diabetes, alongside diet and exercise. The approval follows a favorable recommendation by the European Medicines Agency in May.
The linagliptin/metformin combination sold in Europe as Jentadueto (Boehringer Ingelheim Pharmaceuticals, Inc, and Eli Lilly & Co) provides a single-tablet option that is taken twice daily.
It is intended for patients with type 2 diabetes that is inadequately controlled on their maximal tolerated dose of metformin alone, metformin plus a sulfonylurea, or those already being treated with the combination of linagliptin and metformin. It can be used alone or in combination with a sulfonylurea.
As previously reported by Medscape Medical News, the linagliptin/metformin combination was approved by the US Food and Drug Administration earlier this year.
In a 24-week, randomized, double-blind, placebo-controlled study involving 791 adults with type 2 diabetes inadequately managed with diet and exercise, 2.5 mg linagliptin/1000 mg metformin led to mean reductions in hemoglobin A1c levels of 1.7 percentage points. Statistically significant reductions in fasting plasma glucose (FPG) of −60 mg/dL were also seen.
In clinical studies, linagliptin/metformin did not cause any significant change in body weight.
Adverse reactions were uncommon in clinical studies. Gastrointestinal disorders occurred most often during the initiation period and tended to resolve spontaneously. A comparable rate of diarrhea was reported with linagliptin/metformin treatment vs metformin plus placebo.
Hypoglycemia was more commonly reported in patients treated with the combination of linagliptin/metformin and a sulfonylurea compared with those treated with the combination of placebo, metformin, and a sulfonylurea.
The linagliptin/metformin combination pill is not indicated for patients with type 1 diabetes or those who have diabetic ketoacidosis. It has not been studied in combination with insulin.
Linagliptin/metformin combination tablets will be made available in the following twice-daily doses in Europe: 2.5 mg linagliptin/850 mg metformin tablets and 2.5 mg linagliptin/1000 mg metformin tablets.
Fuente: Medscape
The linagliptin/metformin combination sold in Europe as Jentadueto (Boehringer Ingelheim Pharmaceuticals, Inc, and Eli Lilly & Co) provides a single-tablet option that is taken twice daily.
It is intended for patients with type 2 diabetes that is inadequately controlled on their maximal tolerated dose of metformin alone, metformin plus a sulfonylurea, or those already being treated with the combination of linagliptin and metformin. It can be used alone or in combination with a sulfonylurea.
As previously reported by Medscape Medical News, the linagliptin/metformin combination was approved by the US Food and Drug Administration earlier this year.
In a 24-week, randomized, double-blind, placebo-controlled study involving 791 adults with type 2 diabetes inadequately managed with diet and exercise, 2.5 mg linagliptin/1000 mg metformin led to mean reductions in hemoglobin A1c levels of 1.7 percentage points. Statistically significant reductions in fasting plasma glucose (FPG) of −60 mg/dL were also seen.
In clinical studies, linagliptin/metformin did not cause any significant change in body weight.
Adverse reactions were uncommon in clinical studies. Gastrointestinal disorders occurred most often during the initiation period and tended to resolve spontaneously. A comparable rate of diarrhea was reported with linagliptin/metformin treatment vs metformin plus placebo.
Hypoglycemia was more commonly reported in patients treated with the combination of linagliptin/metformin and a sulfonylurea compared with those treated with the combination of placebo, metformin, and a sulfonylurea.
The linagliptin/metformin combination pill is not indicated for patients with type 1 diabetes or those who have diabetic ketoacidosis. It has not been studied in combination with insulin.
Linagliptin/metformin combination tablets will be made available in the following twice-daily doses in Europe: 2.5 mg linagliptin/850 mg metformin tablets and 2.5 mg linagliptin/1000 mg metformin tablets.
Fuente: Medscape