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Management of type 2 diabetes should include shared decision making, and patients should be offered individualized diabetes self-management education and glycemic management plans, according to a summary of a clinical practice guideline published online Oct. 23 in the Annals of Internal Medicine. Paul R. Conlin, M.D., from the VA Boston Healthcare System in West Roxbury, Massachusetts, and colleagues convened a joint U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) Evidence-Based Practice Work Group to develop a guideline for management of type 2 diabetes mellitus. The authors provided updates on management within seven areas: patient-centered care and shared decision making, glycemic biomarkers, target ranges of hemoglobin A1c (HbA1c), individualized treatment plans, pharmacologic treatment in the outpatient setting, glucose targets for critically ill patients, and treatment for patients in the hospital. Patients should be offered individualized diabetes self-management education, as well as individualized glycemic management plans and target ranges for HbA1c. "In summary, the VA/DoD CPG [clinical practice guideline] attempts to convey to clinicians, policymakers, and patients the rationale for personalizing treatment on the basis of results from major trials, limitations of the HbA1c test, and evaluation of patient risk for adverse drug events. Conveying complex information in an understandable manner to individual patients and families through a formal process of shared decision making is thus foundational to setting and revising goals that are meaningful, safe, and achievable in everyday clinical practice," the authors write.

The American Academy of Family Physicians (AAFP) and the American Board of Family Medicine (ABFM) have launched a new performance improvement activity credit reporting process called the AAFP Credit System, according to an article published by the AAFP. To streamline the overall credit approval process, the AAFP and ABFM developed a system that allows continuing medical education (CME) providers to apply for AAFP Performance Improvement CME Credit and ABFM Certification Activity points for their performance improvement activities through the AAFP Credit System using a single application process. CME providers who apply for credit using the new process only pay one fee and do not have to complete two applications. In addition, for AAFP members reporting eligible CME credit for a performance improvement activity, the ABFM will automatically be notified that the performance improvement certification activity has been completed.

A new screening tool can adequately detect risk of diabetic retinopathy in adults with diabetes in low-income communities in Mexico, according to a study published in the October issue of Preventing Chronic Disease. Kenny Mendoza-Herrera, from the National Institute of Public Health in Mexico, and colleagues analyzed biochemical, clinical, anthropometric, and sociodemographic information from 1,000 adults with diabetes in low-income communities in Mexico in order to develop a screening tool based on a predictive model for early detection of diabetic retinopathy. Time since diabetes diagnosis, high blood glucose levels, systolic hypertension, and physical inactivity were risk factors included in the screening tool. The researchers found that the model had a mean area under the receiver operating characteristic curve (AUC ROC) of 0.78 in the validation data set. Using the optimized cut point that best represented the study population, the model had a sensitivity of 82.9 percent and a specificity of 61.9 percent. "We developed a low-cost and easy-to-apply screening tool to detect people at high risk of diabetic retinopathy in Mexico," the authors write. "Although classification performance of our tool was acceptable (AUC ROC > 0.75), error rates (precision) depend on false-negative and false-positive rates. Therefore, confirmatory assessment of all cases in mandatory."

Higher dietary total fiber and fruit fiber is protective against bone loss at the femoral neck in men, according to a study published online Oct. 12 in the Journal of Bone and Mineral Research. Zhaoli Dai, Ph.D., from the Boston University School of Medicine, and colleagues examined the correlation between dietary fiber, assessed using the Willett food frequency questionnaire, and bone loss at the femoral neck, trochanter, and lumbar spine in older men and women. Bone mineral density was measured using dual-energy X-ray absorptiometry at baseline (1996 to 2011) and in 2001 to 2005 and 2005 to 2008 among 792 men and 1,065 women. The researchers found that in men, but not women, higher dietary total fiber and fruit fiber was protective against bone loss at the femoral neck (P = 0.003 and 0.008, respectively). Compared with men in quartile 1 of fiber intake, those in quartiles 2 to 4 had significantly less bone loss at the femoral neck (all P < 0.04). There were no associations with hip bone loss in women; fiber from vegetables seemed protective against spine bone loss in women but not men. No correlations were seen for cereal fiber or nut and legume fiber with bone loss in men or women.

For patients undergoing right heart catheterization (RHC), borderline pulmonary hypertension (PH) is associated with increased risk of mortality, according to a study published online Oct. 25 in JAMA Cardiology. Tufik R. Assad, M.D., from Vanderbilt University School of Medicine in Nashville, Tennessee, and colleagues conducted a retrospective cohort study involving patients undergoing routine RHC for clinical indication. Patients were classified according to mean pulmonary arterial pressure (mPAP) values as reference, borderline PH, and PH (mPAP values of ≤18, 19 to 24, and ≥25 mmHg, respectively). The researchers found that the prevalence of PH and borderline PH was 62 and 18 percent, respectively, among 4,343 patients. Independent associations were seen for advanced age, features of the metabolic syndrome, and chronic heart and lung disease with increased likelihood of borderline PH versus reference patients. Borderline PH was correlated with increased mortality compared with reference patients after adjustment for 34 variables (hazard ratio, 1.31). With higher mPAP there was an incremental increase in the risk of death, without an observed threshold. Sixty-one percent of the 70 patients with borderline PH who underwent repeated RHC had developed overt PH, with a 5 mmHg median increase in mPAP (interquartile range, -1 to 11 mmHg; P < 0.001).

For young patients with type 1 diabetes, insulin pump therapy is associated with lower risks of severe hypoglycemia and diabetic ketoacidosis and better glycemic control than insulin injection therapy, according to a study published online Oct. 10 in the Journal of the American Medical Association. Beate Karges, M.D., from RWTH Aachen University in Germany, and colleagues conducted a population-based cohort study in 446 diabetes centers. They identified patients with type 1 diabetes who were younger than 20 years and had diabetes duration of more than one year. The researchers found that 14,119 patients used pump therapy and 16,460 used insulin injections. A total of 9,814 patients using pump therapy were matched with 9,814 using injection therapy. Compared with injection therapy, pump therapy was correlated with lower rates of severe hypoglycemia (9.55 versus 13.97 per 100 patient-years) and diabetic ketoacidosis (3.64 versus 4.26 per 100 patient-years). Lower levels of glycated hemoglobin were seen with pump versus injection therapy (8.04 versus 8.22 percent). Compared with injection therapy, pump therapy was associated with lower total daily insulin doses (0.84 versus 0.98 U/kg). No significant difference in body mass index was seen between the treatment regimens

For patients with stage 4 or 5 chronic kidney disease and hepatitis C virus (HCV) infection, 12 weeks of treatment with glecaprevir and pibrentasvir results in a high rate of sustained virologic response, according to a study published online Oct. 11 in the New England Journal of Medicine. Edward Gane, M.D., from Auckland City Hospital in New Zealand, and colleagues conducted a multicenter trial to examine the efficacy and safety of combination treatment with the NS3/4A protease inhibitor glecaprevir and the NS5A inhibitor pibrentasvir for 12 weeks in adults with HCV infection and compensated liver disease with severe renal impairment, dependence on dialysis, or both. Participants had stage 4 or 5 chronic kidney disease. One hundred four patients were enrolled in the trial. The researchers found that the sustained virologic response rate was 98 percent. During treatment, none of the patients had virologic failure, and none had a virologic relapse after the end of treatment. Pruritus, fatigue, and nausea were reported in at least 10 percent of the patients. Twenty-four percent of the patients reported serious adverse events. Because of adverse events, four patients discontinued the trial treatment prematurely; three of these had sustained virologic response

44th Annual Vascular and Endovascular Issues, Techniques, Horizons (VEITH) Symposium is organized by Cleveland Clinic and would be held during Nov 14 - 18, 2017 at New York Hilton Midtown, New York, United States of America. The 5-day event features rapid-fire presentations from world renowned vascular specialists with emphasis on the latest advances, changing concepts in diagnosis and management, pressing controversies and new techniques. Objectives : Upon completion of the VEITHsymposium, the participants will, after learning about a wide array of topics, be able to: * Explain the practical implications of clinical trial data on new technologies and techniques for endovascular repair of abdominal aortic aneurysm and thoracic aortic disease * Summarize the impact of data on therapeutic advances for stroke and carotid disease management * Compare the safety, efficacy, and therapeutic indications of pharmacologic agents to the management of vascular disease * Assess data on the latest state-of-the-art for the treatment of superficial femoral and tibial artery disease and describe potential implications for clinical care * Summarize recent data on treatment advances for venous disease and explain their clinical implications * Provide new information about the latest developments in hemodialysis access and vascular malformations and tumors

Most ophthalmologists write no more than 10 opioid prescriptions annually, with a mean supply per prescription of five days, according to a study published online Oct. 5 in JAMA Ophthalmology. Shriji Patel, M.D., and Paul Sternberg Jr., M.D., both from Vanderbilt Eye Institute in Nashville, Tennessee, analyzed physician and beneficiary measures using Medicare Part D Prescriber Data (2013 to 2015) to determine prescribing patterns for opioid drugs for participating ophthalmologists. The researchers found that, consistently, 88 to 89 percent of ophthalmologists wrote 10 opioid prescriptions or fewer annually. Only about 1 percent of ophthalmologists wrote more than 100 opioid prescriptions annually. On average, ophthalmologists wrote seven opioid prescriptions per year with a mean supply of five days. The six states with the highest volume of annual opioid prescriptions per ophthalmologist were in the South.

Dual-graft (DG) adult living donor liver transplantation (ALDLT) with ABO-incompatible (ABOi) and ABO-compatible (ABOc) graft combination is associated with high rates of graft survival, with no significant difference for ABOi and ABOc grafts, according to research published online July 31 in the American Journal of Transplantation. Jae Hyun Kwon, M.D., from the University of Ulsan College of Medicine in Seoul, South Korea, and colleagues conducted a retrospective review of medical records of patients who underwent ABOi DG ALDLT between 2008 and 2014. The authors also assessed the graft regeneration rate using computed tomography volumetric analysis. During a mean follow-up of 57.0 ± 22.4 months, the researchers found that the one-, three-, and five-year patient survival rate was 96.4 percent. The rate of graft survival at one-, three-, and five-years was 96.4, 94.2, and 92.0 percent, respectively; ABOc and ABOi grafts did not differ significantly (P = 0.145). No significant differences were seen between ABOc and ABOi grafts in the biliary complication rate (P = 0.195). There was no significant difference in regeneration rates for ABOi and ABOc grafts. "DG ALDLT with ABOi and ABOc graft combination seems to be a feasible option for expanding the donor pool without additional donor risks," the authors write.

Ropinirole, bromocriptine, and piribedil are associated with the highest incidence rates of adverse effects in Parkinson's disease, according to a review published online Sept. 4 in CNS Neuroscience & Therapeutics. Bao-Dong Li, from the Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine in China, and colleagues conducted a systematic review to compare the adverse effects of 11 drugs used to treat Parkinson's disease. Data were included from 24 randomized controlled trials. The researchers found that, compared with placebo, the incidence of adverse reactions of ropinirole, rotigotine, entacapone, and sumanirole were higher in terms of nausea. The incidence rates of dyskinesia side effects were highest with ropinirole, while in terms of patients' hallucination, pramipexole was significantly higher. The surface under the cumulative ranking curve values of all drugs showed that the incidence of adverse reaction of pergolide was relatively high (nausea, 83.5 percent; hallucination, 79.8 percent); the incidence of dyskinesia and somnolence was higher with ropinirole (80.5 and 69.4 percent); in terms of dizziness, the incidence of adverse reaction of piribedil was higher (67.0 percent), and in terms of constipation, the incidence of bromocriptine was relatively high (62.3 percent). "In addition to current forms of treatment, we hope that our results can produce useful information for further development of new drugs to treat Parkinson's disease based on the natures of each drug," the authors write.

Immediate access to opioid agonist treatment (OAT) for patients presenting with opioid use disorder may provide greater health benefits at less cost than observed standard of care, according to a study published online Nov. 21 in the Annals of Internal Medicine. Emanuel Krebs, from St. Paul's Hospital in Vancouver, Canada, and colleagues sought to determine the cost-effectiveness of OAT versus observed standard of care for patients presenting with opioid use disorder. Population-level administrative databases capturing treatment and criminal justice records for California were linked (2006 to 2010). Immediate access to OAT for all treatment recipients was found by the researchers to cost less (by $78,257), with patients accumulating more quality-adjusted life-years (by 0.42) versus the observed standard of care. Imagining a hypothetical scenario where all Californians starting treatment of opioid use disorder in 2014 had immediate access to OAT, the team found that total lifetime savings for this cohort could be as high as $3.8 billion.

For patients with unruptured intracranial aneurysms (UIAs) that are 3 mm or smaller, no preventive treatment or imaging follow-up is the most effective management strategy, according to a study published online Nov. 20 in JAMA Neurology. Ajay Malhotra, M.D., from the Yale School of Medicine in New Haven, Conn., and colleagues used inputs from the medical literature to conduct a decision-analytic model-based comparative effectiveness analysis. Five management strategies were assessed: annual magnetic resonance angiography (MRA) screening, biennial MRA screening, MRA screening every five years, aneurysm coiling and follow-up, and no treatment or preventive follow-up. In an analysis of 10,000 iterations simulating adult patients, the researchers found that the highest health benefit was seen for the management strategy of no treatment or preventive follow-up (mean quality-adjusted life-years, 19.40). MRA every five years was the best of the management strategies that incorporate follow-up imaging, with the next highest effectiveness (mean quality-adjusted life-years, 18.05). When the annual growth rate and risk of rupture of growing aneurysms are varied, no routine follow-up remains the optimal strategy. No follow-up is the optimal strategy when the annual risk of rupture of nongrowing UIAs is less than 1.7 percent; coiling should be performed directly if the annual risk of rupture is >1.7 percent.

Most physicians on Twitter with a financial conflict of interest (FCOI) and frequent tweets mention specific drugs for which they have a conflict, according to a study published in the September issue of The Lancet Haematology. Victoria Kaestner, from the Oregon Health & Science University in Portland, and colleagues examined whether conflicted physicians tweet about specific products for which they have a FCOI. A total of 156 physicians who tweeted a median of 584 times were included, with a 2014 median general payment totaling $13,600.

Conjugated linoleic acid (CLA) supplementation is associated with an increase in serum C-reactive protein (CRP) concentration, according to a review and meta-analysis published online May 29 in Cardiovascular Therapeutics. Mohsen Mazidi, Ph.D., from the Chinese Academy of Sciences in Beijing, and colleagues conducted a systematic review and meta-analysis to examine the impact of CLA supplementation on serum CRP. Data were included from 14 studies. The researchers found that following supplementation with CLAs there was a significant increase in serum CRP concentrations (weighted mean difference, 0.63 mg/dL; 95 percent confidence interval, 0.13 to 1.13; heterogeneity P = 0.026); these findings were robust in sensitivity analyses. The changes in serum CRP levels were found to be independent of CLA supplementation dosage (slope, −0.02; 95 percent confidence interval, −0.10 to 0.12; P = 0.889) or follow-up duration (slope, 0.271; 95 percent confidence interval, −0.05 to 0.59; P = 0.098). "This meta-analysis suggests that CLA supplementation is associated with an increase in plasma CRP concentrations and a reduction in serum adiponectin concentrations, which indicates that CLA supplements have a pro-inflammatory effect," the authors write.

More than 78 percent of health care personnel (HCP) and 53.6 percent of pregnant women received influenza vaccination during the 2016-2017 influenza season, according to two studies published in the Sept. 29 issue of Morbidity and Mortality Weekly Report. Carla L. Black, Ph.D., from the U.S. Centers for Disease Control and Prevention (CDC), and colleagues surveyed 2,438 HCP to estimate influenza vaccination coverage. The researchers found that during the 2016-2017 season, 78.6 percent of survey respondents reported receiving vaccination, similar to reported coverage in the previous three seasons. Coverage was highest for those working in hospitals compared with those working in ambulatory or long-term-care settings (92.3 versus 76.1 and 68 percent) and for those who were required by their employer to be vaccinated (96.7 percent), as in previous seasons. Helen Ding, M.D., from the CDC, and colleagues surveyed 1,893 women pregnant at any time during October 2016 to January 2017. The researchers found that 53.6 percent of respondents reported having received influenza vaccination before or during pregnancy (16.2 and 37.4 percent, respectively); this was similar to coverage during the previous four influenza seasons. Overall, 67.3, 11.9, and 20.7 percent of women reported receiving a provider offer for influenza vaccination, receiving a recommendation but no offer, and receiving no recommendation, respectively, similar to the previous influenza season; influenza vaccination coverage was 70.5, 43.7, and 14.8 percent, respectively, among these women.

The incidence of lower urinary tract injuries is 0.33 percent for patients undergoing gynecologic laparoscopy for benign indications, according to a review published online Dec. 4 in Obstetrics & Gynecology. Jacqueline M.K. Wong, M.D., from the Northwestern University Feinberg School of Medicine in Chicago, and colleagues conducted a systematic review of studies to examine the incidence, location, etiology, timing, management, and long-term sequelae of urinary tract injury in gynecologic laparoscopy for benign indication. Ninety studies met the inclusion criteria, representing 140,444 surgeries. The researchers identified 458 lower urinary tract injuries with an incidence of 0.33 percent. Bladder injury occurred three times more often than ureteral injury (0.24 versus 0.08 percent). The highest rates of injury were seen for laparoscopic hysterectomy not otherwise specified and laparoscopically assisted vaginal hysterectomy (1.8 and 1.0 percent, respectively). Most ureteral and bladder injuries resulted from electrosurgery (33.3 percent) and lysis of adhesions (23.3 percent), respectively. Ureteral injuries were most often recognized postoperatively (60 percent) and repaired by open ureteral anastomosis (47.4 percent), while most bladder injuries were recognized intraoperatively (85 percent) and repaired by laparoscopic suturing (34.9 percent).

Intensive blood pressure lowering may similarly decrease cardiovascular events in both patients with and patients without type 2 diabetes mellitus, according to a study published online Dec. 6 in Diabetes Care. Tom F. Brouwer, M.D., from the University of Amsterdam, and colleagues assessed the effect of both type 2 diabetes and baseline cardiovascular disease risk on the treatment effect of intensive blood pressure lowering based on data and pooled analysis from two randomized trials (ACCORD-BP [Action to Control Cardiovascular Risk in Diabetes Blood Pressure]and SPRINT [Systolic Blood Pressure Intervention Trial] studies; total of 14,094 patients). The researchers found that the mean baseline systolic blood pressure was 139.5 mm Hg for the cohort and just over one-third (33.6 percent) had type 2 diabetes. The hazard ratio for the primary composite end point of unstable angina, myocardial infarction, acute heart failure, stroke, and cardiovascular death was 0.82 (P = 0.0017). There was a nonsignificant interaction between intensive blood pressure lowering and type 2 diabetes (P = 0.13). While the 10-year cardiovascular risk was higher in patients with type 2 diabetes, there was no interaction between the risk and treatment effect (P = 0.84).

A novel bioinformatics approach can predict vaccine effectiveness for the influenza season, and indicates that the current vaccines are likely to be effective against H3N2 flu viruses in the U.S. 2017/2018 flu season, according to research published online Nov. 29 in F1000 Research. Slobodan Paessler, D.V.M., Ph.D., from the University of Texas Medical Branch, and Veljko Veljkovic, Ph.D., from Biomed Protection, both in Galveston, Texas, used a bioinformatics platform to predict vaccine effectiveness for the 2017/2018 influenza season in the United States. The hemagglutinin HA1 region of 251 and 113 human H3N2 viruses collected in Australia and the United States from July to September 2017 were analyzed. The informational spectrum method-based phylogenetic analysis of H3N2 viruses was performed to serve as a base for predicting vaccine effectiveness. The researchers found that analyses of Australian viruses generated two clusters; the vaccine virus was placed in the smaller group. As a result, the vaccine was predicted not to be efficient against most Australian H3N2 viruses in the 2017 flu season; low vaccine effectiveness was reported in Australia in the 2017 flu season in accordance with this prediction. The U.S. H3N2 viruses were also grouped into two clusters, but the vaccine virus was placed in the largest cluster encompassing 71 percent of analyzed viruses. Consequently, the vaccine effectiveness is expected not to be suboptimal in the United States.

During cardiopulmonary resuscitation (CPR) performed by males, self-adjusted and nearest kneeling postures are more effective for chest compression, with lower perceived exertion, according to a study published online Oct. 5 in the Journal of Clinical Nursing. S.H. Ho, from The Hong Kong Polytechnic University and Daniel H.K. Chow, Ph.D., from The Education University of Hong Kong, applied a self-controlled repeated-measures design to examine the impact of kneeling posture on chest compression during CPR in males. The authors recruited 18 participants with a qualified first-aid certificate. Each participant performed three sessions of CPR on a mannequin using one of three kneeling postures (farthest, self-adjusted, and nearest) in each. Each session comprised five CPR cycles (30 strokes of chest compression within 18 seconds) in each kneeling posture and lasted two minutes. The researchers found that the efficacy of chest compression was significantly better in the self-adjusted and nearest kneeling postures than in the farthest posture. Similar effect was seen for the self-adjusted and nearest postures, while because of the lower rate of perceived exertion, most participants preferred self-adjusted kneeling posture.