Doug Brunk

SAN DIEGO — A simple nurse-based physician prompt significantly improved the rates of counseling for exercise, diet, and weight control received by primary care patients at high risk for diabetes, results from a multisite study showed.

“Involving nurses in diabetes prevention with simple prompts can lead to improved outcomes,” John M. Boltri, M.D., told this newspaper during a poster session at the annual scientific sessions of the American Diabetes Association.

He and his associates randomized 10 primary care practices to intervention and control groups. Nurses in the intervention group received training on the ADA high-risk criteria for diabetes, how to calculate body mass index, how to use fingerstick glucometers, and how to counsel patients and follow up on glucose results.

Nurses in the control group received no such training.

Patients seen at the practices completed an ADA risk assessment questionnaire in the waiting room. In the intervention group, the nurses scored the questionnaire and if the patient was high risk for diabetes, they prompted the doctor to counsel him or her about exercise, diet, and weight control. The control group received usual care. The investigators then followed patients in both groups for 3 months to determine who received diet, exercise, and weight-reduction plans.

Of the 1,395 patients in the study, 42% had a family history of diabetes and 84% were at high risk for diabetes according to ADA criteria, reported Dr. Boltri, professor of family medicine at Mercer University, Macon, Ga. Their mean age was 50 years and their mean BMI was 30 kg/m2.

At 3 months of follow-up, 15% of patients in the intervention group received exercise plans, compared with only 2% of those in the control group. Patients in the intervention group also received more counseling for diet and weight reduction plans, compared with those in the control group (16% vs. 3%, and 6% vs. 2%, respectively).

When the investigators adjusted for age, gender, ADA risk score, and overweight, patients in the intervention group were eight times more likely than controls to receive a diet plan, six times more likely than controls to receive an exercise plan, and two times more likely than controls to receive a weight-loss plan.

“We were surprised at the magnitude of the difference,” Dr. Boltri said. “The odds ratios were high enough to say that this [prompt] would probably work in most primary care practices.”

The study was funded by the Medcen Community Health Foundation and the Health Resources and Services Administration.

Patients at risk for diabetes were more likely to receive counseling from physicians when nurses prompted them.

SAN DIEGO — A simple nurse-based physician prompt significantly improved the rates of counseling for exercise, diet, and weight control received by primary care patients at high risk for diabetes, results from a multisite study showed.

“Involving nurses in diabetes prevention with simple prompts can lead to improved outcomes,” John M. Boltri, M.D., told this newspaper during a poster session at the annual scientific sessions of the American Diabetes Association.

He and his associates randomized 10 primary care practices to intervention and control groups. Nurses in the intervention group received training on the ADA high-risk criteria for diabetes, how to calculate body mass index, how to use fingerstick glucometers, and how to counsel patients and follow up on glucose results.

Nurses in the control group received no such training.

Patients seen at the practices completed an ADA risk assessment questionnaire in the waiting room. In the intervention group, the nurses scored the questionnaire and if the patient was high risk for diabetes, they prompted the doctor to counsel him or her about exercise, diet, and weight control. The control group received usual care. The investigators then followed patients in both groups for 3 months to determine who received diet, exercise, and weight-reduction plans.

Of the 1,395 patients in the study, 42% had a family history of diabetes and 84% were at high risk for diabetes according to ADA criteria, reported Dr. Boltri, professor of family medicine at Mercer University, Macon, Ga. Their mean age was 50 years and their mean BMI was 30 kg/m2.

At 3 months of follow-up, 15% of patients in the intervention group received exercise plans, compared with only 2% of those in the control group. Patients in the intervention group also received more counseling for diet and weight reduction plans, compared with those in the control group (16% vs. 3%, and 6% vs. 2%, respectively).

When the investigators adjusted for age, gender, ADA risk score, and overweight, patients in the intervention group were eight times more likely than controls to receive a diet plan, six times more likely than controls to receive an exercise plan, and two times more likely than controls to receive a weight-loss plan.

“We were surprised at the magnitude of the difference,” Dr. Boltri said. “The odds ratios were high enough to say that this [prompt] would probably work in most primary care practices.”

The study was funded by the Medcen Community Health Foundation and the Health Resources and Services Administration.

Patients at risk for diabetes were more likely to receive counseling from physicians when nurses prompted them.

SAN DIEGO — A simple nurse-based physician prompt significantly improved the rates of counseling for exercise, diet, and weight control received by primary care patients at high risk for diabetes, results from a multisite study showed.

“Involving nurses in diabetes prevention with simple prompts can lead to improved outcomes,” John M. Boltri, M.D., told this newspaper during a poster session at the annual scientific sessions of the American Diabetes Association.

He and his associates randomized 10 primary care practices to intervention and control groups. Nurses in the intervention group received training on the ADA high-risk criteria for diabetes, how to calculate body mass index, how to use fingerstick glucometers, and how to counsel patients and follow up on glucose results.

Nurses in the control group received no such training.

Patients seen at the practices completed an ADA risk assessment questionnaire in the waiting room. In the intervention group, the nurses scored the questionnaire and if the patient was high risk for diabetes, they prompted the doctor to counsel him or her about exercise, diet, and weight control. The control group received usual care. The investigators then followed patients in both groups for 3 months to determine who received diet, exercise, and weight-reduction plans.

Of the 1,395 patients in the study, 42% had a family history of diabetes and 84% were at high risk for diabetes according to ADA criteria, reported Dr. Boltri, professor of family medicine at Mercer University, Macon, Ga. Their mean age was 50 years and their mean BMI was 30 kg/m2.

At 3 months of follow-up, 15% of patients in the intervention group received exercise plans, compared with only 2% of those in the control group. Patients in the intervention group also received more counseling for diet and weight reduction plans, compared with those in the control group (16% vs. 3%, and 6% vs. 2%, respectively).

When the investigators adjusted for age, gender, ADA risk score, and overweight, patients in the intervention group were eight times more likely than controls to receive a diet plan, six times more likely than controls to receive an exercise plan, and two times more likely than controls to receive a weight-loss plan.

“We were surprised at the magnitude of the difference,” Dr. Boltri said. “The odds ratios were high enough to say that this [prompt] would probably work in most primary care practices.”

The study was funded by the Medcen Community Health Foundation and the Health Resources and Services Administration.

Patients at risk for diabetes were more likely to receive counseling from physicians when nurses prompted them.

SAN DIEGO — Postmenopausal women with newly diagnosed diabetes were more likely to have had a history of breast cancer before their diagnosis than were women without diabetes, results from a large cross-sectional Canadian study showed.

Although the finding supports the hypothesis that breast cancer risk is increased in the prediabetes phase, “there are limitations to our study,” Lorraine Lipscombe, M.D., noted at the annual scientific sessions of the American Diabetes Association.

“Given the cross-sectional design, we cannot exclude the possibility of reverse causality in that breast cancer or its treatment actually increased the risk of diabetes,” said Dr. Lipscombe of the division of endocrinology at the University of Toronto.

“However, there have been no studies in the literature to support this possibility, and there's no known rationale whereby this association might occur,” Dr. Lipscombe said.

A more realistic possibility, she offered, “is that breast cancer increases the opportunity for diabetes diagnosis, representing a detection bias. We also couldn't exclude confounding variables as a possible explanation.”

“We were not able to adjust for other breast cancer risk factors such as family history, reproductive factors, and obesity,” she added.

For the study, which she said is the first of its kind, Dr. Lipscombe and her associates used government health care databases from the province of Ontario to identify women aged 55–79 years who were diagnosed with diabetes from 1994 to 2002 and compare them with their peers without diabetes.

Further, they used a breast cancer registry to identify breast cancer cases in Ontario women from 1964 to the present.

Between 1994 and 2002, there were 82,390 women in Ontario with newly diagnosed diabetes and 411,950 women without diabetes.

“The average age was about 65, but the women with diabetes were a little bit older and were more likely to reside in a lower-income neighborhood,” she said.

The investigators identified prior breast cancers in 3,071 women with newly diagnosed diabetes (3.7%) and in 12,709 women without diabetes (3.1%).

The mean time from breast cancer diagnosis to index date was approximately 8 years.

The unadjusted rates of prior breast cancer were 22% higher among women with newly diagnosed diabetes than among women without diabetes, for an odds ratio of 1.22.

When the investigators adjusted for age, income, and number of primary care visits, the association remained significant.

The adjusted rates of prior breast cancer were 13% higher among women with newly diagnosed diabetes than among women without diabetes, for an odds ratio of 1.13.

“Our results support other studies that have shown a small increase in breast cancer incidence after a diagnosis of diabetes,” she said.

“It also lends support to the temporal relationship between insulin resistance and breast cancer,” Dr. Lipscombe said.

“Our results also suggest that this risk may be greater in the prediabetes phase. However, further prospective studies will be required,” she added.

The study was funded by the Canadian Diabetes Association.

SAN DIEGO — Postmenopausal women with newly diagnosed diabetes were more likely to have had a history of breast cancer before their diagnosis than were women without diabetes, results from a large cross-sectional Canadian study showed.

Although the finding supports the hypothesis that breast cancer risk is increased in the prediabetes phase, “there are limitations to our study,” Lorraine Lipscombe, M.D., noted at the annual scientific sessions of the American Diabetes Association.

“Given the cross-sectional design, we cannot exclude the possibility of reverse causality in that breast cancer or its treatment actually increased the risk of diabetes,” said Dr. Lipscombe of the division of endocrinology at the University of Toronto.

“However, there have been no studies in the literature to support this possibility, and there's no known rationale whereby this association might occur,” Dr. Lipscombe said.

A more realistic possibility, she offered, “is that breast cancer increases the opportunity for diabetes diagnosis, representing a detection bias. We also couldn't exclude confounding variables as a possible explanation.”

“We were not able to adjust for other breast cancer risk factors such as family history, reproductive factors, and obesity,” she added.

For the study, which she said is the first of its kind, Dr. Lipscombe and her associates used government health care databases from the province of Ontario to identify women aged 55–79 years who were diagnosed with diabetes from 1994 to 2002 and compare them with their peers without diabetes.

Further, they used a breast cancer registry to identify breast cancer cases in Ontario women from 1964 to the present.

Between 1994 and 2002, there were 82,390 women in Ontario with newly diagnosed diabetes and 411,950 women without diabetes.

“The average age was about 65, but the women with diabetes were a little bit older and were more likely to reside in a lower-income neighborhood,” she said.

The investigators identified prior breast cancers in 3,071 women with newly diagnosed diabetes (3.7%) and in 12,709 women without diabetes (3.1%).

The mean time from breast cancer diagnosis to index date was approximately 8 years.

The unadjusted rates of prior breast cancer were 22% higher among women with newly diagnosed diabetes than among women without diabetes, for an odds ratio of 1.22.

When the investigators adjusted for age, income, and number of primary care visits, the association remained significant.

The adjusted rates of prior breast cancer were 13% higher among women with newly diagnosed diabetes than among women without diabetes, for an odds ratio of 1.13.

“Our results support other studies that have shown a small increase in breast cancer incidence after a diagnosis of diabetes,” she said.

“It also lends support to the temporal relationship between insulin resistance and breast cancer,” Dr. Lipscombe said.

“Our results also suggest that this risk may be greater in the prediabetes phase. However, further prospective studies will be required,” she added.

The study was funded by the Canadian Diabetes Association.

SAN DIEGO — Postmenopausal women with newly diagnosed diabetes were more likely to have had a history of breast cancer before their diagnosis than were women without diabetes, results from a large cross-sectional Canadian study showed.

Although the finding supports the hypothesis that breast cancer risk is increased in the prediabetes phase, “there are limitations to our study,” Lorraine Lipscombe, M.D., noted at the annual scientific sessions of the American Diabetes Association.

“Given the cross-sectional design, we cannot exclude the possibility of reverse causality in that breast cancer or its treatment actually increased the risk of diabetes,” said Dr. Lipscombe of the division of endocrinology at the University of Toronto.

“However, there have been no studies in the literature to support this possibility, and there's no known rationale whereby this association might occur,” Dr. Lipscombe said.

A more realistic possibility, she offered, “is that breast cancer increases the opportunity for diabetes diagnosis, representing a detection bias. We also couldn't exclude confounding variables as a possible explanation.”

“We were not able to adjust for other breast cancer risk factors such as family history, reproductive factors, and obesity,” she added.

For the study, which she said is the first of its kind, Dr. Lipscombe and her associates used government health care databases from the province of Ontario to identify women aged 55–79 years who were diagnosed with diabetes from 1994 to 2002 and compare them with their peers without diabetes.

Further, they used a breast cancer registry to identify breast cancer cases in Ontario women from 1964 to the present.

Between 1994 and 2002, there were 82,390 women in Ontario with newly diagnosed diabetes and 411,950 women without diabetes.

“The average age was about 65, but the women with diabetes were a little bit older and were more likely to reside in a lower-income neighborhood,” she said.

The investigators identified prior breast cancers in 3,071 women with newly diagnosed diabetes (3.7%) and in 12,709 women without diabetes (3.1%).

The mean time from breast cancer diagnosis to index date was approximately 8 years.

The unadjusted rates of prior breast cancer were 22% higher among women with newly diagnosed diabetes than among women without diabetes, for an odds ratio of 1.22.

When the investigators adjusted for age, income, and number of primary care visits, the association remained significant.

The adjusted rates of prior breast cancer were 13% higher among women with newly diagnosed diabetes than among women without diabetes, for an odds ratio of 1.13.

“Our results support other studies that have shown a small increase in breast cancer incidence after a diagnosis of diabetes,” she said.

“It also lends support to the temporal relationship between insulin resistance and breast cancer,” Dr. Lipscombe said.

“Our results also suggest that this risk may be greater in the prediabetes phase. However, further prospective studies will be required,” she added.

The study was funded by the Canadian Diabetes Association.

SAN DIEGO — With no medical therapy, patients with stage C and D heart failure face a 2-year mortality risk of 35%, Lee Goldberg, M.D., said at the 100th International Conference of the American Thoracic Society.

But clinicians can reduce the 2-year mortality in this population of patients by 12%–24% if they treat patients with the available medical therapies.

“The number needed to treat to save one life is four patients,” said Dr. Goldberg of the heart failure/transplant program at the University of Pennsylvania Health System, Philadelphia.

“So it's extremely cost effective to treat heart failure patients. Many of the medical therapies we have are underutilized—especially in patients who are less symptomatic,” Dr. Goldberg said.

He reviewed the following treatments, commonly used in patients with stage C and D heart failure:

▸ Diuretics. Although there are no clinical trial data proving their efficacy in this patient population, diuretics are the most commonly prescribed drugs for patients with advanced heart failure.

“But we know from epidemiologic data that diuretics don't change the natural history of heart failure,” Dr. Goldberg said. “Morbidity and mortality after taking them doesn't change very much.”

Loop diuretics are the most commonly used type, although many centers augment them with thiazide diuretics.

“I would titrate to signs and symptoms of volume overload,” he advised. “Many disease management programs have action plans of sliding-scale diuretics to help patients control their volume status. It keeps them out of the hospital and keeps them safe, but it doesn't prolong their life, and it doesn't change the [heart] remodeling process.”

The symptomatic benefits of diuretics occur more rapidly than those of other drugs, and diuretics are the only class of drugs that adequately control chronic fluid retention.

Adverse effects may include volume depletion and renal insufficiency. Metabolic effects may include electrolyte imbalance, hyperuricemia, and hyperglycemia.

▸ ACE inhibitors. There are “buckets of data” on the use of these agents in advanced heart failure. ACE inhibitors interfere with the renin-angiotensin system and enhance the action of kinins. “They alleviate symptoms, reduce death, and reduce hospitalizations,” Dr. Goldberg said. “So they hit all three of our goals [in treating these patients]: heart remodeling, symptoms, and mortality.”

These drugs are typically given to all patients with systolic dysfunction. “A lot of people believe they should also be used in diastolic dysfunction, but we don't have good data for that yet,” he said.

Adverse effects may include hypotension, azotemia, hyperkalemia, cough, and angioedema.

Unanswered questions include the issue of whether there is a class effect. “The answer is probably yes,” he said. Also, it is not known whether there is a significant interaction with aspirin. “Most of us are comfortable using both aspirin and ACE inhibitors,” said Dr. Goldberg, also of the University of Pennsylvania.

▸ β-Blockers. These drugs inhibit the adverse effects of the sympathetic system, and they delay and reverse heart remodeling. “The No. 1 way to increase the ejection fraction in patients with heart failure is to actually put them on a β-blocker,” Dr. Goldberg said.

β-Blockers are currently given to all patients with systolic heart failure in the absence of fluid overload. Adverse effects may include hypotension, bradycardia, and worsening heart failure.

The ideal target dose for β-blockers has not been determined. This is one remaining question about this class of drugs. “There is probably not a class effect,” he said. “It appears that the long-acting β-blockers and nonselective β-blockers may have an advantage over the shorter-acting and selective ones.”

▸ Angiotensin II-receptor blockers. These drugs block the effect of angiotensin II at the receptor site. They delay heart remodeling and reduce symptoms, and they have been shown to reduce hospitalizations and deaths. ARBs are currently given to patients who can't tolerate ACE inhibitors—specifically, the side effects of angioedema and cough.

The Valsartan Heart Failure Trial (Val-HeFT) and the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) trial showed some improvement in the efficacy of ARBs when used with ACE inhibitors. However, patients in Val-HeFT who took ARBs with an ACE inhibitor and a β-blocker had worse outcomes. This association was not found in CHARM.

Adverse effects may include hypotension, azotemia, hyperkalemia, and cough.

▸ Digoxin. This drug has no impact on mortality, but it does appear to improve symptoms. Dr. Goldberg cautioned that digoxin carries a high risk of renal insufficiency and an increased risk of drug interactions.

He recommends using the lowest possible dose of the drug and maintaining drug levels below 1.0 ng/mL.

A recent study of heart failure patients found that digoxin had no effect on quality of life, compared with placebo, in terms of perceived health, functioning, depression, anxiety, anger, and the 6-minute walk test (J. Card. Fail. 2003;9:4–12).

▸ Aldosterone antagonists. Trials of these agents show improved mortality for class IIIB or class IV patients, but not in heart failure patients with less severe disease, Dr. Goldberg said.

The role of these drugs with β-blockers is not well defined, and they are contraindicated if patients are on both an ACE inhibitor and an ARB due to a risk of hyperkalemia.

▸ Nitrates. The Vasodilator-Heart Failure Trial (V-HeFT) demonstrated that nitrates in combination with hydralazine are not as effective as ACE inhibitors, yet they are better than placebo.

The African-American Heart Failure Trial (A-HeFT) showed that nitrates and hydralazine improved mortality when used with ACE inhibitors and β-blockers, but their value when added to traditional therapy is unknown in other racial groups.

SAN DIEGO — With no medical therapy, patients with stage C and D heart failure face a 2-year mortality risk of 35%, Lee Goldberg, M.D., said at the 100th International Conference of the American Thoracic Society.

But clinicians can reduce the 2-year mortality in this population of patients by 12%–24% if they treat patients with the available medical therapies.

“The number needed to treat to save one life is four patients,” said Dr. Goldberg of the heart failure/transplant program at the University of Pennsylvania Health System, Philadelphia.

“So it's extremely cost effective to treat heart failure patients. Many of the medical therapies we have are underutilized—especially in patients who are less symptomatic,” Dr. Goldberg said.

He reviewed the following treatments, commonly used in patients with stage C and D heart failure:

▸ Diuretics. Although there are no clinical trial data proving their efficacy in this patient population, diuretics are the most commonly prescribed drugs for patients with advanced heart failure.

“But we know from epidemiologic data that diuretics don't change the natural history of heart failure,” Dr. Goldberg said. “Morbidity and mortality after taking them doesn't change very much.”

Loop diuretics are the most commonly used type, although many centers augment them with thiazide diuretics.

“I would titrate to signs and symptoms of volume overload,” he advised. “Many disease management programs have action plans of sliding-scale diuretics to help patients control their volume status. It keeps them out of the hospital and keeps them safe, but it doesn't prolong their life, and it doesn't change the [heart] remodeling process.”

The symptomatic benefits of diuretics occur more rapidly than those of other drugs, and diuretics are the only class of drugs that adequately control chronic fluid retention.

Adverse effects may include volume depletion and renal insufficiency. Metabolic effects may include electrolyte imbalance, hyperuricemia, and hyperglycemia.

▸ ACE inhibitors. There are “buckets of data” on the use of these agents in advanced heart failure. ACE inhibitors interfere with the renin-angiotensin system and enhance the action of kinins. “They alleviate symptoms, reduce death, and reduce hospitalizations,” Dr. Goldberg said. “So they hit all three of our goals [in treating these patients]: heart remodeling, symptoms, and mortality.”

These drugs are typically given to all patients with systolic dysfunction. “A lot of people believe they should also be used in diastolic dysfunction, but we don't have good data for that yet,” he said.

Adverse effects may include hypotension, azotemia, hyperkalemia, cough, and angioedema.

Unanswered questions include the issue of whether there is a class effect. “The answer is probably yes,” he said. Also, it is not known whether there is a significant interaction with aspirin. “Most of us are comfortable using both aspirin and ACE inhibitors,” said Dr. Goldberg, also of the University of Pennsylvania.

▸ β-Blockers. These drugs inhibit the adverse effects of the sympathetic system, and they delay and reverse heart remodeling. “The No. 1 way to increase the ejection fraction in patients with heart failure is to actually put them on a β-blocker,” Dr. Goldberg said.

β-Blockers are currently given to all patients with systolic heart failure in the absence of fluid overload. Adverse effects may include hypotension, bradycardia, and worsening heart failure.

The ideal target dose for β-blockers has not been determined. This is one remaining question about this class of drugs. “There is probably not a class effect,” he said. “It appears that the long-acting β-blockers and nonselective β-blockers may have an advantage over the shorter-acting and selective ones.”

▸ Angiotensin II-receptor blockers. These drugs block the effect of angiotensin II at the receptor site. They delay heart remodeling and reduce symptoms, and they have been shown to reduce hospitalizations and deaths. ARBs are currently given to patients who can't tolerate ACE inhibitors—specifically, the side effects of angioedema and cough.

The Valsartan Heart Failure Trial (Val-HeFT) and the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) trial showed some improvement in the efficacy of ARBs when used with ACE inhibitors. However, patients in Val-HeFT who took ARBs with an ACE inhibitor and a β-blocker had worse outcomes. This association was not found in CHARM.

Adverse effects may include hypotension, azotemia, hyperkalemia, and cough.

▸ Digoxin. This drug has no impact on mortality, but it does appear to improve symptoms. Dr. Goldberg cautioned that digoxin carries a high risk of renal insufficiency and an increased risk of drug interactions.

He recommends using the lowest possible dose of the drug and maintaining drug levels below 1.0 ng/mL.

A recent study of heart failure patients found that digoxin had no effect on quality of life, compared with placebo, in terms of perceived health, functioning, depression, anxiety, anger, and the 6-minute walk test (J. Card. Fail. 2003;9:4–12).

▸ Aldosterone antagonists. Trials of these agents show improved mortality for class IIIB or class IV patients, but not in heart failure patients with less severe disease, Dr. Goldberg said.

The role of these drugs with β-blockers is not well defined, and they are contraindicated if patients are on both an ACE inhibitor and an ARB due to a risk of hyperkalemia.

▸ Nitrates. The Vasodilator-Heart Failure Trial (V-HeFT) demonstrated that nitrates in combination with hydralazine are not as effective as ACE inhibitors, yet they are better than placebo.

The African-American Heart Failure Trial (A-HeFT) showed that nitrates and hydralazine improved mortality when used with ACE inhibitors and β-blockers, but their value when added to traditional therapy is unknown in other racial groups.

SAN DIEGO — With no medical therapy, patients with stage C and D heart failure face a 2-year mortality risk of 35%, Lee Goldberg, M.D., said at the 100th International Conference of the American Thoracic Society.

But clinicians can reduce the 2-year mortality in this population of patients by 12%–24% if they treat patients with the available medical therapies.

“The number needed to treat to save one life is four patients,” said Dr. Goldberg of the heart failure/transplant program at the University of Pennsylvania Health System, Philadelphia.

“So it's extremely cost effective to treat heart failure patients. Many of the medical therapies we have are underutilized—especially in patients who are less symptomatic,” Dr. Goldberg said.

He reviewed the following treatments, commonly used in patients with stage C and D heart failure:

▸ Diuretics. Although there are no clinical trial data proving their efficacy in this patient population, diuretics are the most commonly prescribed drugs for patients with advanced heart failure.

“But we know from epidemiologic data that diuretics don't change the natural history of heart failure,” Dr. Goldberg said. “Morbidity and mortality after taking them doesn't change very much.”

Loop diuretics are the most commonly used type, although many centers augment them with thiazide diuretics.

“I would titrate to signs and symptoms of volume overload,” he advised. “Many disease management programs have action plans of sliding-scale diuretics to help patients control their volume status. It keeps them out of the hospital and keeps them safe, but it doesn't prolong their life, and it doesn't change the [heart] remodeling process.”

The symptomatic benefits of diuretics occur more rapidly than those of other drugs, and diuretics are the only class of drugs that adequately control chronic fluid retention.

Adverse effects may include volume depletion and renal insufficiency. Metabolic effects may include electrolyte imbalance, hyperuricemia, and hyperglycemia.

▸ ACE inhibitors. There are “buckets of data” on the use of these agents in advanced heart failure. ACE inhibitors interfere with the renin-angiotensin system and enhance the action of kinins. “They alleviate symptoms, reduce death, and reduce hospitalizations,” Dr. Goldberg said. “So they hit all three of our goals [in treating these patients]: heart remodeling, symptoms, and mortality.”

These drugs are typically given to all patients with systolic dysfunction. “A lot of people believe they should also be used in diastolic dysfunction, but we don't have good data for that yet,” he said.

Adverse effects may include hypotension, azotemia, hyperkalemia, cough, and angioedema.

Unanswered questions include the issue of whether there is a class effect. “The answer is probably yes,” he said. Also, it is not known whether there is a significant interaction with aspirin. “Most of us are comfortable using both aspirin and ACE inhibitors,” said Dr. Goldberg, also of the University of Pennsylvania.

▸ β-Blockers. These drugs inhibit the adverse effects of the sympathetic system, and they delay and reverse heart remodeling. “The No. 1 way to increase the ejection fraction in patients with heart failure is to actually put them on a β-blocker,” Dr. Goldberg said.

β-Blockers are currently given to all patients with systolic heart failure in the absence of fluid overload. Adverse effects may include hypotension, bradycardia, and worsening heart failure.

The ideal target dose for β-blockers has not been determined. This is one remaining question about this class of drugs. “There is probably not a class effect,” he said. “It appears that the long-acting β-blockers and nonselective β-blockers may have an advantage over the shorter-acting and selective ones.”

▸ Angiotensin II-receptor blockers. These drugs block the effect of angiotensin II at the receptor site. They delay heart remodeling and reduce symptoms, and they have been shown to reduce hospitalizations and deaths. ARBs are currently given to patients who can't tolerate ACE inhibitors—specifically, the side effects of angioedema and cough.

The Valsartan Heart Failure Trial (Val-HeFT) and the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) trial showed some improvement in the efficacy of ARBs when used with ACE inhibitors. However, patients in Val-HeFT who took ARBs with an ACE inhibitor and a β-blocker had worse outcomes. This association was not found in CHARM.

Adverse effects may include hypotension, azotemia, hyperkalemia, and cough.

▸ Digoxin. This drug has no impact on mortality, but it does appear to improve symptoms. Dr. Goldberg cautioned that digoxin carries a high risk of renal insufficiency and an increased risk of drug interactions.

He recommends using the lowest possible dose of the drug and maintaining drug levels below 1.0 ng/mL.

A recent study of heart failure patients found that digoxin had no effect on quality of life, compared with placebo, in terms of perceived health, functioning, depression, anxiety, anger, and the 6-minute walk test (J. Card. Fail. 2003;9:4–12).

▸ Aldosterone antagonists. Trials of these agents show improved mortality for class IIIB or class IV patients, but not in heart failure patients with less severe disease, Dr. Goldberg said.

The role of these drugs with β-blockers is not well defined, and they are contraindicated if patients are on both an ACE inhibitor and an ARB due to a risk of hyperkalemia.

▸ Nitrates. The Vasodilator-Heart Failure Trial (V-HeFT) demonstrated that nitrates in combination with hydralazine are not as effective as ACE inhibitors, yet they are better than placebo.

The African-American Heart Failure Trial (A-HeFT) showed that nitrates and hydralazine improved mortality when used with ACE inhibitors and β-blockers, but their value when added to traditional therapy is unknown in other racial groups.

SAN DIEGO — Moderate exercise equivalent to a brisk 1-hour walk 4 days a week improved insulin sensitivity in a group of women with polycystic ovary syndrome, even in the absence of weight loss, results from a small trial suggest.

The finding is important because obese women with polycystic ovary syndrome (PCOS) “have often been told to lose weight,” Ann J. Brown, M.D., told this newspaper during a poster session at the annual meeting of the Androgen Excess Society. “They know that they need to lose weight, but it's very difficult [for them]. This is a hopeful message that even just picking up the pace of activity will improve your metabolic profile.”

For the 5-month study, she and her associates randomized 19 sedentary women aged 22–41 years with PCOS to one of two groups. One group of 11 women continued their sedentary lifestyle, while another group of 8 women participated in a monitored exercise program that equaled about 230 min/wk at 60% maximal oxygen uptake, “the equivalent of a brisk walk,” said Dr. Brown of the division of endocrinology, metabolism, and nutrition in the department of medicine at Duke University Medical Center, Durham, N.C.

Study participants completed a 75-g oral glucose tolerance test and a frequently sampled intravenous glucose tolerance test before and after the intervention. The investigators calculated insulin sensitivity and area under the curve (AUC) for glucose and insulin.

At baseline, the women in both groups were similar in age, aerobic fitness level, body mass index, blood pressure, fasting insulin, insulin AUC, and insulin sensitivity. At the end of 5 months, aerobic fitness in the sedentary group worsened by 2.3%, compared with a 4.3% improvement in the exercise group, a statistically significant difference. BMI and waist circumference did not change in either group.

Fasting insulin decreased significantly in the exercise group, compared with the sedentary group (−4.6% vs. +8.9%), as did insulin AUC (−26.0% vs. +1.4%).

SAN DIEGO — Moderate exercise equivalent to a brisk 1-hour walk 4 days a week improved insulin sensitivity in a group of women with polycystic ovary syndrome, even in the absence of weight loss, results from a small trial suggest.

The finding is important because obese women with polycystic ovary syndrome (PCOS) “have often been told to lose weight,” Ann J. Brown, M.D., told this newspaper during a poster session at the annual meeting of the Androgen Excess Society. “They know that they need to lose weight, but it's very difficult [for them]. This is a hopeful message that even just picking up the pace of activity will improve your metabolic profile.”

For the 5-month study, she and her associates randomized 19 sedentary women aged 22–41 years with PCOS to one of two groups. One group of 11 women continued their sedentary lifestyle, while another group of 8 women participated in a monitored exercise program that equaled about 230 min/wk at 60% maximal oxygen uptake, “the equivalent of a brisk walk,” said Dr. Brown of the division of endocrinology, metabolism, and nutrition in the department of medicine at Duke University Medical Center, Durham, N.C.

Study participants completed a 75-g oral glucose tolerance test and a frequently sampled intravenous glucose tolerance test before and after the intervention. The investigators calculated insulin sensitivity and area under the curve (AUC) for glucose and insulin.

At baseline, the women in both groups were similar in age, aerobic fitness level, body mass index, blood pressure, fasting insulin, insulin AUC, and insulin sensitivity. At the end of 5 months, aerobic fitness in the sedentary group worsened by 2.3%, compared with a 4.3% improvement in the exercise group, a statistically significant difference. BMI and waist circumference did not change in either group.

Fasting insulin decreased significantly in the exercise group, compared with the sedentary group (−4.6% vs. +8.9%), as did insulin AUC (−26.0% vs. +1.4%).

SAN DIEGO — Moderate exercise equivalent to a brisk 1-hour walk 4 days a week improved insulin sensitivity in a group of women with polycystic ovary syndrome, even in the absence of weight loss, results from a small trial suggest.

The finding is important because obese women with polycystic ovary syndrome (PCOS) “have often been told to lose weight,” Ann J. Brown, M.D., told this newspaper during a poster session at the annual meeting of the Androgen Excess Society. “They know that they need to lose weight, but it's very difficult [for them]. This is a hopeful message that even just picking up the pace of activity will improve your metabolic profile.”

For the 5-month study, she and her associates randomized 19 sedentary women aged 22–41 years with PCOS to one of two groups. One group of 11 women continued their sedentary lifestyle, while another group of 8 women participated in a monitored exercise program that equaled about 230 min/wk at 60% maximal oxygen uptake, “the equivalent of a brisk walk,” said Dr. Brown of the division of endocrinology, metabolism, and nutrition in the department of medicine at Duke University Medical Center, Durham, N.C.

Study participants completed a 75-g oral glucose tolerance test and a frequently sampled intravenous glucose tolerance test before and after the intervention. The investigators calculated insulin sensitivity and area under the curve (AUC) for glucose and insulin.

At baseline, the women in both groups were similar in age, aerobic fitness level, body mass index, blood pressure, fasting insulin, insulin AUC, and insulin sensitivity. At the end of 5 months, aerobic fitness in the sedentary group worsened by 2.3%, compared with a 4.3% improvement in the exercise group, a statistically significant difference. BMI and waist circumference did not change in either group.

Fasting insulin decreased significantly in the exercise group, compared with the sedentary group (−4.6% vs. +8.9%), as did insulin AUC (−26.0% vs. +1.4%).

SAN DIEGO — Nonalcoholic fatty liver disease is common in women with polycystic ovary syndrome, regardless of their body mass index, a retrospective analysis of 88 patients has shown.

Although the prevalence of nonalcoholic fatty liver disease in lean women in the general population ranges from 3% to 16%, the prevalence in lean women with polycystic ovary syndrome (PCOS) in this study was 39%.

“We expected [the association], but I think the degree of prevalence is surprising,” Sanjiv Kinkhabwala, M.D., of the division of endocrinology, diabetes, and bone diseases at Mount Sinai School of Medicine, New York, reported in a poster session at the annual meeting of the Androgen Excess Society.

He and his associate, Walter Futterweit, M.D., retrospectively evaluated 88 consecutive premenopausal women with PCOS seen between April and November 2004. The patients denied heavy alcohol use and known liver disease, and all had PCOS. Nonalcoholic fatty liver disease was diagnosed by prospective abdominal ultrasound.

The investigators grouped the women by body mass index (BMI), defining lean as having a BMI of less than 25 kg/m

Of the 88 women, 48 (55%) had nonalcoholic fatty liver disease. The prevalence of the disease among lean, overweight, and obese patients was 39%, 54%, and 70%, respectively.

Patients with fatty liver disease had higher median BMI, ALT level, insulin resistance (based on premetformin homeostatic assessment), and gamma-glutamyl transferase level, as well as a lower median fasting HDL cholesterol level, compared with women who did not have the disease.

Only 7 of the 48 patients with fatty liver disease (15%) had elevated liver chemistries. “Only checking the liver chemistries is insufficient,” he said. “In someone with a BMI of 25, one should do an ultrasound of the abdomen and pelvis.”

SAN DIEGO — Nonalcoholic fatty liver disease is common in women with polycystic ovary syndrome, regardless of their body mass index, a retrospective analysis of 88 patients has shown.

Although the prevalence of nonalcoholic fatty liver disease in lean women in the general population ranges from 3% to 16%, the prevalence in lean women with polycystic ovary syndrome (PCOS) in this study was 39%.

“We expected [the association], but I think the degree of prevalence is surprising,” Sanjiv Kinkhabwala, M.D., of the division of endocrinology, diabetes, and bone diseases at Mount Sinai School of Medicine, New York, reported in a poster session at the annual meeting of the Androgen Excess Society.

He and his associate, Walter Futterweit, M.D., retrospectively evaluated 88 consecutive premenopausal women with PCOS seen between April and November 2004. The patients denied heavy alcohol use and known liver disease, and all had PCOS. Nonalcoholic fatty liver disease was diagnosed by prospective abdominal ultrasound.

The investigators grouped the women by body mass index (BMI), defining lean as having a BMI of less than 25 kg/m

Of the 88 women, 48 (55%) had nonalcoholic fatty liver disease. The prevalence of the disease among lean, overweight, and obese patients was 39%, 54%, and 70%, respectively.

Patients with fatty liver disease had higher median BMI, ALT level, insulin resistance (based on premetformin homeostatic assessment), and gamma-glutamyl transferase level, as well as a lower median fasting HDL cholesterol level, compared with women who did not have the disease.

Only 7 of the 48 patients with fatty liver disease (15%) had elevated liver chemistries. “Only checking the liver chemistries is insufficient,” he said. “In someone with a BMI of 25, one should do an ultrasound of the abdomen and pelvis.”

SAN DIEGO — Nonalcoholic fatty liver disease is common in women with polycystic ovary syndrome, regardless of their body mass index, a retrospective analysis of 88 patients has shown.

Although the prevalence of nonalcoholic fatty liver disease in lean women in the general population ranges from 3% to 16%, the prevalence in lean women with polycystic ovary syndrome (PCOS) in this study was 39%.

“We expected [the association], but I think the degree of prevalence is surprising,” Sanjiv Kinkhabwala, M.D., of the division of endocrinology, diabetes, and bone diseases at Mount Sinai School of Medicine, New York, reported in a poster session at the annual meeting of the Androgen Excess Society.

He and his associate, Walter Futterweit, M.D., retrospectively evaluated 88 consecutive premenopausal women with PCOS seen between April and November 2004. The patients denied heavy alcohol use and known liver disease, and all had PCOS. Nonalcoholic fatty liver disease was diagnosed by prospective abdominal ultrasound.

The investigators grouped the women by body mass index (BMI), defining lean as having a BMI of less than 25 kg/m

Of the 88 women, 48 (55%) had nonalcoholic fatty liver disease. The prevalence of the disease among lean, overweight, and obese patients was 39%, 54%, and 70%, respectively.

Patients with fatty liver disease had higher median BMI, ALT level, insulin resistance (based on premetformin homeostatic assessment), and gamma-glutamyl transferase level, as well as a lower median fasting HDL cholesterol level, compared with women who did not have the disease.

Only 7 of the 48 patients with fatty liver disease (15%) had elevated liver chemistries. “Only checking the liver chemistries is insufficient,” he said. “In someone with a BMI of 25, one should do an ultrasound of the abdomen and pelvis.”

SAN DIEGO — Women with diabetes and untreated depression who become pregnant face a host of risks to themselves and their fetus if their conditions are not managed properly, Laura J. Miller, M.D., warned at the annual scientific sessions of the American Diabetes Association.

These women face the risk of “decreased prenatal care, decreased ability to meet the nutritional demands of pregnancy—either because of eating too little in general or not eating healthy foods—and an increased risk of addictive substance abuse, which in turn can be teratogenic. Most notably, that includes alcohol consumption and cigarette smoking. They both go up with untreated depression during pregnancy,” said Dr. Miller, a psychiatrist who directs the women's mental health program at the University of Illinois at Chicago.

The potential effects on pregnancy outcome are “significantly bad.” in the sense that untreated depression, even in the absence of diabetes, “increases low birth weight in offspring, increases the risk of premature birth, increases rates of preeclampsia, and increases neonatal irritability,” Dr. Miller said.

“Even in the absence of other confounding factors, if you compare newborns just a few hours after birth, born to mothers with untreated depression during their pregnancy as opposed to other newborns, you'll find excessive crying, difficulty with sleep, fussiness, and difficulty being soothed.”

Some of the ill effects of depression on diabetes could be related to the diabetes disease process itself, Dr. Miller said. For example, elevated cortisol is relatively common in depression and can affect blood glucose levels. Even so, she maintained that most of the effects of depression in women with diabetes appear to be due to decrements in diabetes self-care. “That's on every level: less adherence to diet and as a result, higher body mass index, less physical activity, more smoking, less self-monitoring of blood sugar levels, and less adherence to diabetic medication,” she said.

Dr. Miller discussed the telltale signs of untreated clinical depression and how those symptoms could influence diabetes outcomes:

▸ Enduring depressed mood or anhedonic state. A woman with diabetes who is anhedonic “will have a difficult time caring about themselves to follow through with self-care for diabetes,” Dr. Miller said.

▸ Changes in appetite and weight. This could involve increased or decreased appetite “and often an appetite for different kinds of foods—often very sugary foods—and changes in sleep that, in turn, affect changes in appetite and weight,” she said. “This could directly influence blood glucose control in diabetes.”

▸ Psychomotor retardation. The resulting sense of fatigue or feeling of less energy brought on by this symptom could influence a person's metabolic rate and exercise level.

▸ Feelings of guilt or worthlessness. “Some people just don't feel that they're worth the bother of diabetes self-care,” she observed.

▸ Impaired concentration. This may result in the woman's inability to remember whether she took her insulin or oral hypoglycemic “and taking too much or too little as a result.”

▸ Thoughts of death, including suicidal thoughts. Dr. Miller said it is not uncommon for people with diabetes to use insulin in a suicide attempt.

“Looking at all of those symptoms, it should not surprise us that studies almost consistently find strong links between depression and diabetes,” she said.

Depression during pregnancy can cause women to engage in risky behaviors, such as smoking. Lolita Jones

SAN DIEGO — Women with diabetes and untreated depression who become pregnant face a host of risks to themselves and their fetus if their conditions are not managed properly, Laura J. Miller, M.D., warned at the annual scientific sessions of the American Diabetes Association.

These women face the risk of “decreased prenatal care, decreased ability to meet the nutritional demands of pregnancy—either because of eating too little in general or not eating healthy foods—and an increased risk of addictive substance abuse, which in turn can be teratogenic. Most notably, that includes alcohol consumption and cigarette smoking. They both go up with untreated depression during pregnancy,” said Dr. Miller, a psychiatrist who directs the women's mental health program at the University of Illinois at Chicago.

The potential effects on pregnancy outcome are “significantly bad.” in the sense that untreated depression, even in the absence of diabetes, “increases low birth weight in offspring, increases the risk of premature birth, increases rates of preeclampsia, and increases neonatal irritability,” Dr. Miller said.

“Even in the absence of other confounding factors, if you compare newborns just a few hours after birth, born to mothers with untreated depression during their pregnancy as opposed to other newborns, you'll find excessive crying, difficulty with sleep, fussiness, and difficulty being soothed.”

Some of the ill effects of depression on diabetes could be related to the diabetes disease process itself, Dr. Miller said. For example, elevated cortisol is relatively common in depression and can affect blood glucose levels. Even so, she maintained that most of the effects of depression in women with diabetes appear to be due to decrements in diabetes self-care. “That's on every level: less adherence to diet and as a result, higher body mass index, less physical activity, more smoking, less self-monitoring of blood sugar levels, and less adherence to diabetic medication,” she said.

Dr. Miller discussed the telltale signs of untreated clinical depression and how those symptoms could influence diabetes outcomes:

▸ Enduring depressed mood or anhedonic state. A woman with diabetes who is anhedonic “will have a difficult time caring about themselves to follow through with self-care for diabetes,” Dr. Miller said.

▸ Changes in appetite and weight. This could involve increased or decreased appetite “and often an appetite for different kinds of foods—often very sugary foods—and changes in sleep that, in turn, affect changes in appetite and weight,” she said. “This could directly influence blood glucose control in diabetes.”

▸ Psychomotor retardation. The resulting sense of fatigue or feeling of less energy brought on by this symptom could influence a person's metabolic rate and exercise level.

▸ Feelings of guilt or worthlessness. “Some people just don't feel that they're worth the bother of diabetes self-care,” she observed.

▸ Impaired concentration. This may result in the woman's inability to remember whether she took her insulin or oral hypoglycemic “and taking too much or too little as a result.”

▸ Thoughts of death, including suicidal thoughts. Dr. Miller said it is not uncommon for people with diabetes to use insulin in a suicide attempt.

“Looking at all of those symptoms, it should not surprise us that studies almost consistently find strong links between depression and diabetes,” she said.

Depression during pregnancy can cause women to engage in risky behaviors, such as smoking. Lolita Jones

SAN DIEGO — Women with diabetes and untreated depression who become pregnant face a host of risks to themselves and their fetus if their conditions are not managed properly, Laura J. Miller, M.D., warned at the annual scientific sessions of the American Diabetes Association.

These women face the risk of “decreased prenatal care, decreased ability to meet the nutritional demands of pregnancy—either because of eating too little in general or not eating healthy foods—and an increased risk of addictive substance abuse, which in turn can be teratogenic. Most notably, that includes alcohol consumption and cigarette smoking. They both go up with untreated depression during pregnancy,” said Dr. Miller, a psychiatrist who directs the women's mental health program at the University of Illinois at Chicago.

The potential effects on pregnancy outcome are “significantly bad.” in the sense that untreated depression, even in the absence of diabetes, “increases low birth weight in offspring, increases the risk of premature birth, increases rates of preeclampsia, and increases neonatal irritability,” Dr. Miller said.

“Even in the absence of other confounding factors, if you compare newborns just a few hours after birth, born to mothers with untreated depression during their pregnancy as opposed to other newborns, you'll find excessive crying, difficulty with sleep, fussiness, and difficulty being soothed.”

Some of the ill effects of depression on diabetes could be related to the diabetes disease process itself, Dr. Miller said. For example, elevated cortisol is relatively common in depression and can affect blood glucose levels. Even so, she maintained that most of the effects of depression in women with diabetes appear to be due to decrements in diabetes self-care. “That's on every level: less adherence to diet and as a result, higher body mass index, less physical activity, more smoking, less self-monitoring of blood sugar levels, and less adherence to diabetic medication,” she said.

Dr. Miller discussed the telltale signs of untreated clinical depression and how those symptoms could influence diabetes outcomes:

▸ Enduring depressed mood or anhedonic state. A woman with diabetes who is anhedonic “will have a difficult time caring about themselves to follow through with self-care for diabetes,” Dr. Miller said.

▸ Changes in appetite and weight. This could involve increased or decreased appetite “and often an appetite for different kinds of foods—often very sugary foods—and changes in sleep that, in turn, affect changes in appetite and weight,” she said. “This could directly influence blood glucose control in diabetes.”

▸ Psychomotor retardation. The resulting sense of fatigue or feeling of less energy brought on by this symptom could influence a person's metabolic rate and exercise level.

▸ Feelings of guilt or worthlessness. “Some people just don't feel that they're worth the bother of diabetes self-care,” she observed.

▸ Impaired concentration. This may result in the woman's inability to remember whether she took her insulin or oral hypoglycemic “and taking too much or too little as a result.”

▸ Thoughts of death, including suicidal thoughts. Dr. Miller said it is not uncommon for people with diabetes to use insulin in a suicide attempt.

“Looking at all of those symptoms, it should not surprise us that studies almost consistently find strong links between depression and diabetes,” she said.

Depression during pregnancy can cause women to engage in risky behaviors, such as smoking. Lolita Jones

SAN DIEGO — The rate of diabetes-related, potentially preventable hospitalizations in the United States fell by 35% between 1994 and 2002, Michael M. Engelgau, M.D., reported at a press briefing during the annual scientific sessions of the American Diabetes Association.

The rate of hospitalizations refers to the number of admissions per total number of people with diabetes in the United States.

Although the exact cause of the reduction was not studied, the declines in hospitalizations “are representative of good care,” said Dr. Engelgau, associate director for prevention policy in the division of diabetes translation at the Centers for Disease Control and Prevention.

“This could be [because] the diabetic population is growing very quickly in the United States,” he suggested. “Maybe it's a slightly healthier population [with diabetes that] doesn't need hospitalization quite as much. Or there could be changes in some of the hospitalization practices in the various health care systems in the United States. Some of these factors are coming into play. We can't say exactly how important those are, but the bottom line is that this does seem to be a very positive trend in these types of potentially preventable hospitalizations.”

To study the number of preventable hospitalizations, Dr. Engelgau and his associates used the Healthcare Cost and Utilization Project National Inpatient Sample from 1994–2002. This sample consists of about 80% of hospitalizations in 35 states and is weighted to represent the nation.

The researchers zeroed in on four conditions that can be avoided with high-quality outpatient care, or can be less severe if treated early and correctly: uncontrolled diabetes, short-term complications such as diabetic ketoacidosis, long-term complications such as chronic kidney disease, and lower extremity amputations.

Between 1994 and 2002, the number of diabetes-related preventable hospitalizations in the United States increased from 439,000 in 1994 to 473,000 in 2002. Total costs for the hospitalizations increased from $4 billion in 1994 to $9.5 billion in 2002.

During the same time, people diagnosed with diabetes increased from 8.1 million in 1994 to 13.3 million in 2002. As a result, the rate of diabetes-related preventable hospital admissions decreased from 55 per 1,000 people with diabetes to 36 per 1,000 people with diabetes, a decline of 35%.

Of the four diabetes-related conditions studied, admission rates for uncontrolled diabetes had the largest decline, from 10 per 1,000 people with diabetes in 1994 to 4 per 1,000 in 2002. The hospital admission rate for long-term complications also had a large decline, from 28 per 1,000 people with diabetes in 1994 to 20 per 1,000 in 2002.

SAN DIEGO — The rate of diabetes-related, potentially preventable hospitalizations in the United States fell by 35% between 1994 and 2002, Michael M. Engelgau, M.D., reported at a press briefing during the annual scientific sessions of the American Diabetes Association.

The rate of hospitalizations refers to the number of admissions per total number of people with diabetes in the United States.

Although the exact cause of the reduction was not studied, the declines in hospitalizations “are representative of good care,” said Dr. Engelgau, associate director for prevention policy in the division of diabetes translation at the Centers for Disease Control and Prevention.

“This could be [because] the diabetic population is growing very quickly in the United States,” he suggested. “Maybe it's a slightly healthier population [with diabetes that] doesn't need hospitalization quite as much. Or there could be changes in some of the hospitalization practices in the various health care systems in the United States. Some of these factors are coming into play. We can't say exactly how important those are, but the bottom line is that this does seem to be a very positive trend in these types of potentially preventable hospitalizations.”

To study the number of preventable hospitalizations, Dr. Engelgau and his associates used the Healthcare Cost and Utilization Project National Inpatient Sample from 1994–2002. This sample consists of about 80% of hospitalizations in 35 states and is weighted to represent the nation.

The researchers zeroed in on four conditions that can be avoided with high-quality outpatient care, or can be less severe if treated early and correctly: uncontrolled diabetes, short-term complications such as diabetic ketoacidosis, long-term complications such as chronic kidney disease, and lower extremity amputations.

Between 1994 and 2002, the number of diabetes-related preventable hospitalizations in the United States increased from 439,000 in 1994 to 473,000 in 2002. Total costs for the hospitalizations increased from $4 billion in 1994 to $9.5 billion in 2002.

During the same time, people diagnosed with diabetes increased from 8.1 million in 1994 to 13.3 million in 2002. As a result, the rate of diabetes-related preventable hospital admissions decreased from 55 per 1,000 people with diabetes to 36 per 1,000 people with diabetes, a decline of 35%.

Of the four diabetes-related conditions studied, admission rates for uncontrolled diabetes had the largest decline, from 10 per 1,000 people with diabetes in 1994 to 4 per 1,000 in 2002. The hospital admission rate for long-term complications also had a large decline, from 28 per 1,000 people with diabetes in 1994 to 20 per 1,000 in 2002.

SAN DIEGO — The rate of diabetes-related, potentially preventable hospitalizations in the United States fell by 35% between 1994 and 2002, Michael M. Engelgau, M.D., reported at a press briefing during the annual scientific sessions of the American Diabetes Association.

The rate of hospitalizations refers to the number of admissions per total number of people with diabetes in the United States.

Although the exact cause of the reduction was not studied, the declines in hospitalizations “are representative of good care,” said Dr. Engelgau, associate director for prevention policy in the division of diabetes translation at the Centers for Disease Control and Prevention.

“This could be [because] the diabetic population is growing very quickly in the United States,” he suggested. “Maybe it's a slightly healthier population [with diabetes that] doesn't need hospitalization quite as much. Or there could be changes in some of the hospitalization practices in the various health care systems in the United States. Some of these factors are coming into play. We can't say exactly how important those are, but the bottom line is that this does seem to be a very positive trend in these types of potentially preventable hospitalizations.”

To study the number of preventable hospitalizations, Dr. Engelgau and his associates used the Healthcare Cost and Utilization Project National Inpatient Sample from 1994–2002. This sample consists of about 80% of hospitalizations in 35 states and is weighted to represent the nation.

The researchers zeroed in on four conditions that can be avoided with high-quality outpatient care, or can be less severe if treated early and correctly: uncontrolled diabetes, short-term complications such as diabetic ketoacidosis, long-term complications such as chronic kidney disease, and lower extremity amputations.

Between 1994 and 2002, the number of diabetes-related preventable hospitalizations in the United States increased from 439,000 in 1994 to 473,000 in 2002. Total costs for the hospitalizations increased from $4 billion in 1994 to $9.5 billion in 2002.

During the same time, people diagnosed with diabetes increased from 8.1 million in 1994 to 13.3 million in 2002. As a result, the rate of diabetes-related preventable hospital admissions decreased from 55 per 1,000 people with diabetes to 36 per 1,000 people with diabetes, a decline of 35%.

Of the four diabetes-related conditions studied, admission rates for uncontrolled diabetes had the largest decline, from 10 per 1,000 people with diabetes in 1994 to 4 per 1,000 in 2002. The hospital admission rate for long-term complications also had a large decline, from 28 per 1,000 people with diabetes in 1994 to 20 per 1,000 in 2002.

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited-English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper. “In some of those states, the number tripled between the 1990 and 2000 census.”

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” aims “to focus on the practical things that you can do in your clinic, and it gives you a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide.

Written by Cynthia E. Roat, author of a training guide for medical interpreters in the United States, the tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English-proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess them for your practice.

▸ Step 3: Implement the right mix of services for your practice and patient population. The guide gives examples of ways to do this, as well as a case study illustrating the steps one primary care practice took to improve care of patients who speak limited English.

The tool kit also includes sample language-access policies and procedures and a sample job description for a bilingual staff interpreter.

“The important thing is to provide quality care to patients that do not speak English,” said Eric Ramos, M.D., a family physician in Modesto, Calif., who helped develop the guide. “Many of us use children or significant others as translators. Most of the time it works out well if it's an adult—a friend or family member. But a lot of times we'll use children, which is probably not the most appropriate way to get information,” noted Dr. Ramos, current president of the California Academy of Family Physicians.

The California Endowment provided financial support for the guide.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited-English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper. “In some of those states, the number tripled between the 1990 and 2000 census.”

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” aims “to focus on the practical things that you can do in your clinic, and it gives you a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide.

Written by Cynthia E. Roat, author of a training guide for medical interpreters in the United States, the tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English-proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess them for your practice.

▸ Step 3: Implement the right mix of services for your practice and patient population. The guide gives examples of ways to do this, as well as a case study illustrating the steps one primary care practice took to improve care of patients who speak limited English.

The tool kit also includes sample language-access policies and procedures and a sample job description for a bilingual staff interpreter.

“The important thing is to provide quality care to patients that do not speak English,” said Eric Ramos, M.D., a family physician in Modesto, Calif., who helped develop the guide. “Many of us use children or significant others as translators. Most of the time it works out well if it's an adult—a friend or family member. But a lot of times we'll use children, which is probably not the most appropriate way to get information,” noted Dr. Ramos, current president of the California Academy of Family Physicians.

The California Endowment provided financial support for the guide.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited-English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper. “In some of those states, the number tripled between the 1990 and 2000 census.”

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” aims “to focus on the practical things that you can do in your clinic, and it gives you a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide.

Written by Cynthia E. Roat, author of a training guide for medical interpreters in the United States, the tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English-proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess them for your practice.

▸ Step 3: Implement the right mix of services for your practice and patient population. The guide gives examples of ways to do this, as well as a case study illustrating the steps one primary care practice took to improve care of patients who speak limited English.

The tool kit also includes sample language-access policies and procedures and a sample job description for a bilingual staff interpreter.

“The important thing is to provide quality care to patients that do not speak English,” said Eric Ramos, M.D., a family physician in Modesto, Calif., who helped develop the guide. “Many of us use children or significant others as translators. Most of the time it works out well if it's an adult—a friend or family member. But a lot of times we'll use children, which is probably not the most appropriate way to get information,” noted Dr. Ramos, current president of the California Academy of Family Physicians.

The California Endowment provided financial support for the guide.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper. “In some of those states, the number tripled between the 1990 and 2000 census.”

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” aims “to focus on the practical things that you can do in your clinic, and it gives you a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide. “It really is meant for people to be able to look through the options and resources to pick and choose what would fit their practice.”

Written by Cynthia E. Roat, author of a training guide for medical interpreters in the United States, the tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess each for your type of practice.

▸ Step 3: Implement the right mix of services for your practice and patient population. The guide gives examples of ways to do this, as well as a case study illustrating the steps one primary care practice took to improve care of patients who speak limited English.

The tool kit also includes sample language-access policies and procedures, a sample job description for a bilingual staff interpreter, and a sample interpreter service waiver.

“The important thing is to provide quality care to patients that do not speak English,” said Eric Ramos, M.D., president of the California Academy of Family Physicians, who also helped develop the guide. “Many of us use children or significant others as translators. A lot of times we'll use children, which is probably not the most appropriate way to get information.”

The California Endowment provided financial support for the guide.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper. “In some of those states, the number tripled between the 1990 and 2000 census.”

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” aims “to focus on the practical things that you can do in your clinic, and it gives you a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide. “It really is meant for people to be able to look through the options and resources to pick and choose what would fit their practice.”

Written by Cynthia E. Roat, author of a training guide for medical interpreters in the United States, the tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess each for your type of practice.

▸ Step 3: Implement the right mix of services for your practice and patient population. The guide gives examples of ways to do this, as well as a case study illustrating the steps one primary care practice took to improve care of patients who speak limited English.

The tool kit also includes sample language-access policies and procedures, a sample job description for a bilingual staff interpreter, and a sample interpreter service waiver.

“The important thing is to provide quality care to patients that do not speak English,” said Eric Ramos, M.D., president of the California Academy of Family Physicians, who also helped develop the guide. “Many of us use children or significant others as translators. A lot of times we'll use children, which is probably not the most appropriate way to get information.”

The California Endowment provided financial support for the guide.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper. “In some of those states, the number tripled between the 1990 and 2000 census.”

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” aims “to focus on the practical things that you can do in your clinic, and it gives you a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide. “It really is meant for people to be able to look through the options and resources to pick and choose what would fit their practice.”

Written by Cynthia E. Roat, author of a training guide for medical interpreters in the United States, the tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess each for your type of practice.

▸ Step 3: Implement the right mix of services for your practice and patient population. The guide gives examples of ways to do this, as well as a case study illustrating the steps one primary care practice took to improve care of patients who speak limited English.

The tool kit also includes sample language-access policies and procedures, a sample job description for a bilingual staff interpreter, and a sample interpreter service waiver.

“The important thing is to provide quality care to patients that do not speak English,” said Eric Ramos, M.D., president of the California Academy of Family Physicians, who also helped develop the guide. “Many of us use children or significant others as translators. A lot of times we'll use children, which is probably not the most appropriate way to get information.”

The California Endowment provided financial support for the guide.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

SAN DIEGO — A new drug helps slow accelerated red blood cell destruction that is a characteristic feature of sickle cell disease, Kenneth I. Ataga, M.D., reported at a press briefing during the annual meeting of the American Society of Hematology.

The drug, known as ICA-17043, is part of new class of drugs known as Gardos channel inhibitors. Potassium loss from red blood cells (RBCs) may occur via the Gardos channel, explained Dr. Ataga of the University of North Carolina, Chapel Hill. ICA-17043 blocks this channel and prevents accelerated potassium efflux, which in turn prevents dehydration of RBCs.

In a 12-week, multicenter, phase II study, he and his associates randomized 80 patients with sickle cell anemia to one of three groups: low dose ICA-17043 (6 mg/day), high dose ICA17043 (10 mg/day), or placebo. Total hemoglobin increased significantly from baseline among patients in the high-dose group and markers of RBC destruction decreased, compared with those in the placebo group.

SAN DIEGO — A new drug helps slow accelerated red blood cell destruction that is a characteristic feature of sickle cell disease, Kenneth I. Ataga, M.D., reported at a press briefing during the annual meeting of the American Society of Hematology.

The drug, known as ICA-17043, is part of new class of drugs known as Gardos channel inhibitors. Potassium loss from red blood cells (RBCs) may occur via the Gardos channel, explained Dr. Ataga of the University of North Carolina, Chapel Hill. ICA-17043 blocks this channel and prevents accelerated potassium efflux, which in turn prevents dehydration of RBCs.

In a 12-week, multicenter, phase II study, he and his associates randomized 80 patients with sickle cell anemia to one of three groups: low dose ICA-17043 (6 mg/day), high dose ICA17043 (10 mg/day), or placebo. Total hemoglobin increased significantly from baseline among patients in the high-dose group and markers of RBC destruction decreased, compared with those in the placebo group.

SAN DIEGO — A new drug helps slow accelerated red blood cell destruction that is a characteristic feature of sickle cell disease, Kenneth I. Ataga, M.D., reported at a press briefing during the annual meeting of the American Society of Hematology.

The drug, known as ICA-17043, is part of new class of drugs known as Gardos channel inhibitors. Potassium loss from red blood cells (RBCs) may occur via the Gardos channel, explained Dr. Ataga of the University of North Carolina, Chapel Hill. ICA-17043 blocks this channel and prevents accelerated potassium efflux, which in turn prevents dehydration of RBCs.

In a 12-week, multicenter, phase II study, he and his associates randomized 80 patients with sickle cell anemia to one of three groups: low dose ICA-17043 (6 mg/day), high dose ICA17043 (10 mg/day), or placebo. Total hemoglobin increased significantly from baseline among patients in the high-dose group and markers of RBC destruction decreased, compared with those in the placebo group.