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    <recommendedItem id="20100101_19_383"
                     title="Primary Concerns of MDs, Diabetics Not Always the Same (CME/CE)"
                     score="0.012"
                     href="http://www.medpagetoday.com/Endocrinology/Diabetes/tb/18274?impressionId=1265820175774"
                     
      Diabetic patients aren&apos;t as concerned about their hypertension as their physicians are, researchers found.&lt;br&gt;
&lt;br&gt;In a prospective cohort study, 38% of physicians ranked hypertension as one of their most important concerns for their diabetic patients, while only 18% of those patients ranked hypertension among their most important, Donna M. Zulman, MD, of the University of Michigan Medical School and the Ann Arbor VA, and colleagues reported online in the&lt;em&gt; Journal of General Internal Medicine&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;&quot;If a patient and their doctor do not agree on which of these issues should be prioritized, it will be difficult for them to come up with an effective treatment plan together,&quot; Zulman said in a statement.&lt;/p&gt;
&lt;p&gt;Generally, however, patients&apos; health concerns were similar to their physicians&apos;, as 60% of patient-provider pairs listed the same top three heath concerns.&lt;/p&gt;
&lt;p&gt;On average, diabetics have at least three other chronic health conditions, which can affect treatment, the researchers said.&lt;/p&gt;
&lt;p&gt;To assess concordance of patient and physician priorities, they surveyed 1,169 patients with a primary care visit at any of nine Veterans Affairs facilities in three Midwestern states. They also surveyed the patients&apos; 92 physicians.&lt;/p&gt;
&lt;p&gt;They found that 4% had no matching health concerns, 25% had one matching concern, 55% had two, and 16% had three matches.&lt;/p&gt;
&lt;p&gt;Both patients and providers ranked diabetes and hypertension most frequently in their top three concerns.&lt;/p&gt;
&lt;p&gt;The most obvious disconnect: 38% of physicians ranked hypertension as the most important factor, compared with 18% of patients.&lt;/p&gt;
&lt;p&gt;&quot;This is consistent with previous findings that many diabetic patients are unaware of the importance of blood pressure control despite evidence and guidelines that emphasize the critical importance of this issue,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;Patients were more likely than providers to list losing weight or being more active in their top three concerns (35% versus 21%, respectively).&lt;/p&gt;
&lt;p&gt;They were also more likely to prioritize pain and depression than their doctors were.&lt;/p&gt;
&lt;p&gt;The researchers characterized this finding as &quot;concerning&quot; because it suggests that providers aren&apos;t aware of how seriously these conditions affect their patients. Also, pain and depression can be barriers to effective diabetes self-management, they noted.&lt;/p&gt;
&lt;p&gt;&quot;Both sets of priorities are valid,&quot; Zulman said in a statement. &quot;However, we know from previous studies that issues like pain interfere with a person&apos;s ability to manage their diabetes. So putting these types of symptomatic problems on the back-burner might lead to worse outcomes in diabetes and other chronic conditions.&quot;&lt;/p&gt;
&lt;p&gt;While 60% of patient-provider pairs listed the same top three heath concerns, 28% had much lower concordance. The discord was strongest among the sickest patients, the researchers said, and the probability of concordance decreased significantly when a patient reported competing demands or poor health status (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.01).&lt;/p&gt;
&lt;p&gt;&quot;One possible explanation for this is that patients with poor health or competing demands may be more likely to face functional limitations, financial stress, and other barriers to care,&quot; Zulman added. &quot;For these patients, symptomatic problems might be of utmost importance because they exacerbate their existing challenges.&quot;&lt;/p&gt;
&lt;p&gt;The disconnect may also reflect a breakdown in communication, as the physician may not fully realize how conditions affect health and well-being and may not effectively communicate morbidity and mortality risks, the researchers suggested.&lt;/p&gt;
&lt;p&gt;The study was limited because all participants were aware of diabetes and hypertension status, so it may not be unexpected that the majority of participants ranked both conditions among their top three concerns. The researchers cautioned that this could limit the study&apos;s ability to fully evaluate concordance patterns.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the Robert Wood Johnson Clinical Scholars Program and an associated VA Advanced Fellowship, as well as grants from the US Department of Veterans Affairs Health Services Research and Development Service and the Michigan Diabetes Research and Training Center.&lt;/p&gt;&lt;p&gt;A co-author is supported by an award from the American Cancer Society.&lt;/p&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_280"
                     title="Better Overall Diabetes Care Lowers Nephropathy Risk (CME/CE)"
                     score="0.004"
                     href="http://www.medpagetoday.com/Nephrology/Diabetes/tb/18136?impressionId=1265820175774"
                     
      &lt;p&gt;Simultaneously achieving tight glucose control and other targets in diabetes reduces the risk of kidney complications, researchers found.&lt;/p&gt;
&lt;p&gt;An aggressive multifactorial intervention appeared to delay diabetic nephropathy better when more targets were achieved (&lt;em&gt;P&lt;/em&gt;=0.002 for trend) in a longitudinal study of Chinese patients led by Ming-Chia Hsieh, MD, PhD, of Kaohsiung Medical University Hospital in Kaohsiung, Taiwan.&lt;/p&gt;
&lt;p&gt;The risk of new-onset microalbuminaria dropped 27.1% for those who met the American Diabetes Association-recommended goal of less than 7% glycosylated hemoglobin (&lt;em&gt;P&lt;/em&gt;=0.03), the researchers reported in the Jan. 25 &lt;em&gt;Archives of Internal Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Reaching the systolic blood pressure goal of less than 130 mm Hg reduced this risk 35.5% (&lt;em&gt;P&lt;/em&gt;=0.002). Achieving the HDL cholesterol goal  --  over 50 mg/dL for women and 40 mg/dL for men  --  reduced the risk by 28.5% (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;&quot;The control of microalbuminuria may halt progress to overt nephropathy and reduce occurrence of cardiovascular events in these patients,&quot; Hsieh&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;They suggested that this type of intensive intervention &quot;can be used at the very early stages of diabetic renal disease.&quot;&lt;/p&gt;
&lt;p&gt;Prior studies had suggested that intensive therapy could prevent nephropathy in patients who had already started showing signs of progression.&lt;/p&gt;
&lt;p&gt;So to see if starting earlier would be as effective, Hsieh and colleagues initiated a longitudinal cohort study of 1,290 patients with type 2 diabetes and normoalbuminuria in which participants received intensified treatment to meet ADA-recommended goals on glucose, blood pressure, cholesterol, and triglycerides.&lt;/p&gt;
&lt;p&gt;To this end, patients got the combined efforts of a physician, nurse, and dietitian working together on counseling and patient education to modify behavior.&lt;/p&gt;
&lt;p&gt;By the end of the intervention patients were more likely to have switched from single agent glucose-lowering treatment to insulin plus an oral hypoglycemic agent and to have gone on an antihypertensive (74% versus 48% baseline), statin (58.1% versus 28.0% baseline), and fibrate (14.0% versus 3.0% baseline).&lt;/p&gt;
&lt;p&gt;By the end of the study period, the mean glycosylated hemoglobin was 7.3%, while blood pressure averaged 129.3/74.4 mm Hg. Mean LDL cholesterol was 98.6 mg/dL, triglycerides were at 116.0 mg/dL, and mean HDL cholesterol was 53.6 mg/dL.&lt;/p&gt;
&lt;p&gt;Over the 4.5 years of follow-up, 16.4% of patients developed new-onset microalbuminuria.&lt;/p&gt;
&lt;p&gt;Unlike attainment of HDL cholesterol, glycosylated hemoglobin, and systolic blood pressure goals, reaching those for LDL cholesterol, diastolic blood pressure, and triglycerides appeared to have little impact on kidney function.&lt;/p&gt;
&lt;p&gt;But the more targets patients reached, the less likely they were to develop microalbuminuria (&lt;em&gt;P&lt;/em&gt;=0.002).&lt;/p&gt;
&lt;p&gt;The majority of participants in the study reached one or two of the treatment targets (71.4%) and 8.1% achieved three.&lt;/p&gt;
&lt;p&gt;Those who did reach two or three of the goals were at significantly lower risk of new-onset microalbuminuria than the 20.5% who didn&apos;t reach any of the goals (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Those who reached one target tended to be at lower risk as well, but the effect was not significant compared with reaching none of the goals (&lt;em&gt;P&lt;/em&gt;=0.35).&lt;/p&gt;
&lt;p&gt;One of the concerns with the tight glucose control goal has been hypoglycemia. In the study, 217 patients had at least one episode. Four cases involved major hypoglycemia, though without clinical morbidity or mortality.&lt;/p&gt;
&lt;p&gt;Overall, 37 patients died from any cause during the study period.&lt;/p&gt;
&lt;p&gt;A &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; target=&quot;_blank&quot;&gt;review&lt;/a&gt; of recent large trials of aggressive glycemic control  --  U.K. Prospective Diabetes Study (UKPDS) and the U.S.-based ACCORD, ADVANCE, and VA Diabetes trials  --  suggested a two- to threefold increased risk of severe hypoglycemia without macrovascular benefits.&lt;/p&gt;
&lt;p&gt;In the recent &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/9739&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/9739&quot; target=&quot;_blank&quot;&gt;ACCORD&lt;/a&gt; trial, tight glucose control that brought hemoglobin A1c close to 6%, with a target of less than the standard 7.0%, resulted in 22% excess mortality risk.&lt;/p&gt;
&lt;p&gt;The search for a reason behind this risk has yet to turn up a culprit. &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/ADA/14635&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/ADA/14635&quot; target=&quot;_blank&quot;&gt;Analyses&lt;/a&gt; have suggested that hypoglycemia isn&apos;t to blame and that the lower A1c levels themselves aren&apos;t a problem.&lt;/p&gt;
&lt;p&gt;In the wake of the negative findings from ACCORD, ADVANCE, and the VA trials, leading diabetologists had suggested that pushing too hard in people who couldn&apos;t reach the targets might have been at fault.&lt;/p&gt;
&lt;p&gt;Rather than a one-size-fits all approach, the ADA guidelines suggest individualizing treatment targets.&lt;/p&gt;
&lt;p&gt;Hsieh&apos;s group acknowledged that &quot;even with close attention, not all our patients could achieve the ADA-recommended goals,&quot; but re-emphasized that for patients who could achieve targets, there were benefits.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that their study was limited by lack of a comparison group, no data on genetic factors, and use of potentially arbitrary treatment target cutoff points.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
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                     title="Pioglitazone (Actos) May Cut Heart Risk in Diabetics with Kidney Disease"
                     score="-0.005"
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