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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=1265758107417"
                     
      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_235"
                     title="Congenital Anomalies Linked to Mom&apos;s Diabetes (CME/CE)"
                     score="0.001"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18065?impressionId=1265758107417"
                     
      &lt;p&gt;Pregestational maternal diabetes was associated with an increased risk of a major congenital anomaly, but obesity itself was not, a cross-sectional study found.&lt;/p&gt;
&lt;p&gt;In a multivariable logistic model, the major contributor to a rising rate of congenital anomalies was maternal pregestational diabetes (OR 3.8, 95% CI 2.1 to 6.6), according to Joseph R. Biggio, Jr., MD, and colleagues from the University of Alabama at Birmingham.&lt;/p&gt;
&lt;p&gt;&quot;Because hyperglycemia is a major contributor to developmental malformations, interventions to address obesity and identify women at risk for diabetes and hyperglycemia should be considered in efforts to reduce the occurrence of congenital anomalies,&quot; they wrote in the February issue of &lt;em&gt;Obstetrics &amp;amp; Gynecology.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Maternal obesity has been linked with numerous problems, including preeclampsia, gestational diabetes, fetal and neonatal death, and birth trauma, but scientists have disagreed over whether it also contributes to the risk of fetal malformations, the researchers noted.&lt;/p&gt;
&lt;p&gt;To help settle the issue, Biggio and colleagues used a perinatal database in their university health system that included all women with singletons delivered between 1991 and 2004.&lt;/p&gt;
&lt;p&gt;They divided the cohort into three time periods  --  1991 to 1994, 1995 to 1999, and 2000 to 2004, with a total of 41,902 pregnancies.&lt;/p&gt;
&lt;p&gt;For their primary analysis, they defined maternal obesity as a first prenatal visit weight greater than 200 lb, because during the earlier epochs many women did not have body mass index (BMI) calculated. For their secondary analyses they used BMI greater than 29 kg/m&lt;sup&gt;2&lt;/sup&gt; as the criterion for obesity.&lt;/p&gt;
&lt;p&gt;In each epoch, there were increases in mean maternal weight, mean BMI, the proportion of women weighing more than 200 lb, the proportion with a BMI greater than 29 kg/m&lt;sup&gt;2&lt;/sup&gt;, and the prevalence of pregestational diabetes (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for all).&lt;/p&gt;
&lt;p&gt;Univariable analysis determined that the rate of major anomalies, particularly involving the cardiac and pulmonary systems, also increased during each time period.&lt;/p&gt;
&lt;p&gt;But there was no independent association between congenital anomalies and maternal obesity using either definition, during any of the three time periods or during the study overall.&lt;/p&gt;
&lt;p&gt;Although no direct association was seen between congenital malformations and maternal obesity, the investigators reported that the proportion of anomalies that could be attributed to obesity increased from 0% to 23% during the overall study period.&lt;/p&gt;
&lt;p&gt;The proportion of anomalies that could be attributed to diabetes ranged from 58% to 76%.&lt;/p&gt;
&lt;p&gt;Moreover, for obese women with diabetes the proportion of anomalies attributed to diabetes increased sharply, from 48% in the first epoch to 74% in the third epoch.&lt;/p&gt;
&lt;p&gt;In contrast, for the obstetric population as a whole, the population-attributable risk of congenital malformation related to obesity rose from near zero in the first epoch to 6.1% in the third epoch, while that related to diabetes increased from 3.3% to 9.2%, the investigators reported.&lt;/p&gt;
&lt;p&gt;During the course of the study there was a nearly 15-lb increase in maternal weight and a 30% increase in the proportion of women whose BMI exceeded 29 kg/m&lt;sup&gt;2&lt;/sup&gt;.&lt;/p&gt;
&lt;p&gt;There also was a nearly twofold increase in the rate of major anomalies  --  and a 250% increase in the prevalence of diabetes.&lt;/p&gt;
&lt;p&gt;The authors observed that there has been much interest in the effects of maternal obesity on birth defects.&lt;/p&gt;
&lt;p&gt;Although the pathophysiologic basis for this possible association have not been identified, hypotheses have included increased serum insulin, lower levels of folic acid, chronic hypoxia, and increased inflammatory mediators.&lt;/p&gt;
&lt;p&gt;&quot;Our study provides evidence that the defects may not be due solely to the maternal obesity per se but may be due to undiagnosed diabetes,&quot; the investigators wrote.&lt;/p&gt;
&lt;p&gt;From a public health standpoint, the study findings suggest that efforts to reduce the prevalence of congenital anomalies should be focused less on obesity and aimed more closely at correcting hyperglycemia.&lt;/p&gt;
&lt;p&gt;&quot;If euglycemia could be achieved before pregnancy, or at least embryogenesis and organogenesis, the majority of these anomalies could potentially be avoided,&quot; they observed.&lt;/p&gt;
&lt;p&gt;They also suggested that even women of normal weight, but with other diabetes risk factors, could benefit from closer attention to glycemic control.&lt;/p&gt;
&lt;p&gt;A weakness of the study was the fact that detailed data on glycemic control was not available in the perinatal database, &quot;and therefore we cannot comment on the association between glycemic control and anomaly rates,&quot; the investigators wrote.&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 in part by the National Institute of Child Health and Human Development.&lt;/p&gt;&lt;p&gt;The authors did not report any potential conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_736"
                     title="Study Sheds Light On Birth Defects In Diabetic Pregnancy"
                     score="-0.005"
                     href="