Use of Serum c-Peptide Level to Simplify Diabetes Treatment Regimens in Older Adults

Abstract

Background
Diabetes management in older adults is challenging. Poor glycemic control and high risk of hypoglycemia are common in older patients on a complicated insulin regimen. Newer oral hypoglycemic agents have provided an opportunity to simplify regimens in patients with type-2 diabetes on insulin. Serum c-peptide is a test to assess endogenous production of insulin. We analyze the use of serum c-peptide level in simplifying diabetes regimen by decreasing or stopping insulin injection and adding oral hypoglycemic agents in older adults.

Methods
One hundred patients aged over 65 years with either poor glycemic control or difficulty coping with insulin regimen seen at a geriatric diabetes clinic were analyzed for this study. The data on serum c-peptide levels and A1c, along with demographic information, were obtained from medical charts.

Results
Sixty-five of 100 patients (aged 79 ± 14 years, duration of diabetes 21 ± 13 years) had detectable serum c-peptide levels. Forty-six of 65 patients were available for simplification of regimen. Eleven of 46 patients had other co-morbidities preventing use of oral hypoglycemic agents. In 35/65 patients, simplification was completed successfully. Nineteen of 35 patients were converted to all-oral regimens (off insulin), while 16/35 had simplification of regimen by addition of oral hypoglycemic agents and lowering the number of insulin injections from an average of 2.7 to 1.5 injections/day (P = .001). Glycemic control improved significantly in patients with a simplified regimen (8.0% ± 1.5% vs 7.4% ± 1.5%; P < .002), and patients reported fewer hypoglycemia episodes.

Conclusions
Serum c-peptide level can be used to simplify insulin regimen in older adults with diabetes.

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Medha N. Munshi, MD, Mellody Hayes, BA, Adrianne Sternthala, Darlene Ayres, RN

This article was originally published in the April 2009 issue of The American Journal of Medicine.

AJM Editorial Board Looks to the Future

Last week in Tucson,The American Journal of Medicine's editors and staff met with representatives from Elsevier, the Journal's publisher, to discuss the future of medical publishing and to chart a course for AJM's future.

Through general meetings and targeted workshops, Elsevier Senior Vice President Glen Campbell (below), Publishing Director Pamela M. Poppalardo, Editor-in-Chief Joseph S. Alpert, MD (right), Managing Editor Pamela J. Powers, MPH, Associate Editors, Specialty Editors, and editorial office staff discussed print and electronic publishing and generated new ideas to improve The American Journal of Medicine.

Although many innovative and interesting ideas were brought forth in these face-to-face meetings, the AJM board unanimously agreed to invite our blog readers to suggest ways to improve the print Journal, AJM's website, and/or the AJM blog. If you would like the editorial board and staff to consider making any changes in our current offerings, please comment on the blog. Alternatively, you are welcome to write to editors@amjmed.org.

Depression and Clinical Outcomes in Heart Failure: An OPTIMIZE-HF Analysis

Hospitalized patients with heart failure and a history of depression were less likely to receive cardiac procedures and some education components during hospitalization, and referral to an outpatient heart failure disease management program at discharge. Hospital length of stay was longer and all-cause mortality was higher in patients with a history of depression.

Abstract
Background
Depression is a risk factor of excessive morbidity and mortality in heart failure. We examined in-hospital treatment and postdischarge outcomes in hospitalized heart failure patients with a documented history of depression from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure.

Methods
We identified patient factors associated with depression history and evaluated the association of depression with hospital treatments and mortality, and early postdischarge mortality, emergency care, and rehospitalization.

Results
In 48,612 patients from 259 hospitals, depression history was present in 10.6% and occurred more often in females, whites, and those with common heart failure comorbidities, including chronic pulmonary obstructive disease (36% vs 27%), anemia (27% vs 16.5%), insulin-dependent diabetes mellitus (20% vs 16%), and hyperlipidemia (38% vs 31%), all P <.001. Patients with depression history were less likely to receive coronary interventions and cardiac devices, all P <.01; or be referred to outpatient disease management programs, P <.001. Length of hospital stay was longer with depression history (7.0 vs 6.4 days, P <.001). In 5791 patients followed-up at 60-90 days postdischarge, those with depression history had higher mortality (8.8% vs 6.4%; P = .025). After multivariable modeling, depression history remained a predictor of length of hospital stay, P <.001 and postdischarge mortality, P = .02.

Conclusions
Depression history at heart failure hospitalization may be a predictor of prolonged length of hospital stay, less use of cardiac procedures and postdischarge disease management, and increased 60-90 day mortality. Patients with depression might represent a vulnerable group in which improved use of evidence-based treatment should be considered.

To read this article in its entirety, please visit our website.

-- Nancy M. Albert, PhD, Gregg C. Fonarow, MD, William T. Abraham, MD, Mihai Gheorghiade, MD, Barry H. Greenberg, MD, Eduardo Nunez, MD, Christopher M. O'Connor, MD, Wendy G. Stough, PharmD, Clyde W. Yancy, MD, James B. Young, MD

This article was originally published in the April 2009 issue of The American Journal of Medicine.

Renal Effects of Anti-angiogenesis Therapy: Update for the Internist

Anti-vascular endothelial growth factor therapy is a promising treatment option for patients with many solid cancers. As we learn more about benefits of anti-angiogenesis agents, we should also be aware of their potential adverse reactions.

Abstract
Angiogenesis has become an innovative target in cancer therapy. Agents that inhibit vascular endothelial growth factor (VEGF), one of the most potent promoters of angiogenesis, and its receptor have significant implications for clinical practice. Bevacizumab, sorafenib, sunitinib and other anti-VEGF drugs are frequently complicated by mild proteinuria and hypertension. Other unique renal effects, such as high-grade proteinuria and acute kidney injury, have been described. The most common histopathologic kidney lesion is thrombotic microangiopathy, with other glomerular lesions and interstitial nephritis occurring less frequently. The mechanism for anti-VEGF therapy-induced hypertension is not well understood; however, nitric oxide pathway inhibition, rarefaction, and oxidative stress may be important in its pathogenesis. Glomerular injury may develop from loss of VEGF effect on maintaining the filtration barrier. Adverse effects of anti-VEGF class of drugs are manageable but require close attention and follow-up. Understanding the fundamentals of anti-VEGF drugs' mechanism of action and their clinical implications is crucial when caring for patients receiving anti-VEGF therapy.

To read this article in its entirety, please visit our website.

Faina Gurevich, MD, Mark A. Perazella, MD

This article was originally published in the April 2009 issue of The American Journal of Medicine.

I lost three more pounds on the Brown Bag Diet

I lost three more pounds on the Brown Bag Diet. Now I'm at 178.
April 5th 2009

It wasn't easy but I went back to the basics. AWARENESS, PORTION CONTROL & EAT BY THE CLOCK.

As you know, the last time I reported I had slipped off the track and actually gained two pounds. So I went back to the drawing board to find the three principles (Watchword/Slogans) that helped me lose weight as I started this program. It helped me lose the two pounds I had gained plus put another pound into the loss column.

You can see by my slow weight loss that this is not one of those weekend starvation programs. But you can see how plugging at it little by little I'm shedding the pounds. I'm still not slim enough to fit into my old army fatigues. But with an additional five pound loss I should be able to squeeze into them.

So today's watchword/slogan is: KEEP ON PLUGGING. You can reach your goal if you stay with the course.

Of course you can reach me at BrownBagDiet@gmail.com. And if you do write me I'll try to cheer you on so you too can begin or continue your weight loss program.

Reflections on the Changing Aspects of Aortic Stenosis in the 21st Century

When I was a medical student 40 years ago, aortic stenosis was almost always the result of rheumatic heart disease. These days, rheumatic aortic valve disease has nearly vanished in the US. However, aortic stenosis is still quite common on the wards of our hospitals. What accounts for this change in valvular heart disease etiology, and why is aortic stenosis now so common?

The answer to the questions just posed is 2-fold…

To read this article in its entirety, please visit our website.

-- Joseph S. Alpert, MD
Editor-in-Chief, The American Journal of Medicine

This article was originally published in the April 2009 issue of The American Journal of Medicine.

Comorbidities, Patient Knowledge, and Disease Management in a National Sample of Patients with COPD

Comorbidities are common in chronic obstructive pulmonary disease (COPD) and likely add to the complexity and cost of care. Patient self-knowledge about COPD is lower than for cardiovascular comorbidities. COPD is undertreated compared with generally asymptomatic, less morbid conditions such as hypertension.

Abstract
Objective
COPD is the fourth leading cause of death in the United States but is often undertreated. COPD often overlaps with other conditions such as hypertension and osteoporosis, which are less morbid but may be treated more aggressively. We evaluated the prevalence of these comorbid conditions and compared testing, patient knowledge, and management in a national sample of patients with COPD.

Methods
A survey was administered by telephone in 2006 to 1003 patients with COPD to evaluate the prevalence of comorbid conditions, diagnostic testing, knowledge, and management using standardized instruments. The completion rate was 87%.

Results
Among 1003 patients with COPD, 61% reported moderate or severe dyspnea and 41% reported a prior hospitalization for COPD. The most prevalent comorbid diagnoses were hypertension (55%), hypercholesterolemia (52%), depression (37%), cataracts (31%), and osteoporosis (28%). Only 10% of respondents knew their forced expiratory volume in 1 second (95% confidence interval [CI], 8-12) compared with 79% who knew their blood pressure (95% CI, 76-83). Seventy-two percent (95% CI, 69-75) reported taking any medication for COPD, usually a short-acting bronchodilator, whereas 87% (95% CI, 84-90) of patients with COPD and hypertension were taking an antihypertensive medication and 72% (95% CI, 68-75) of patients with COPD and hypercholesterolemia were taking a statin.

Conclusion
Although most patients with COPD in this national sample were symptomatic and many had been hospitalized for COPD, COPD self-knowledge was low and COPD was undertreated compared with generally asymptomatic, less morbid conditions such as hypertension.

To read this article in its entirety, please visit our website.

-- R. Graham Barr, MD, DrPH, Bartolome R. Celli, MD, David M. Mannino, MD, Thomas Petty, MD, Stephen I. Rennard, MD, Frank C. Sciurba, MD, James K. Stoller, MD, MS, Byron M. Thomashow, MD, Gerard M. Turino, MD

This article was originally published in the April 2009 issue of The American Journal of Medicine.

Atypical Dengue Fever Mimicking Typhoid Fever in a College Student Traveler

Dengue virus belongs to the family flaviviridae, a group of approximately 70 viruses, of which 30—6 commonly—have been associated with human disease. These are: dengue, yellow fever, West Nile encephalitis, St. Louis encephalitis, Japanese encephalitis, and tick-borne encephalitis. All are single-stranded RNA viruses that share common envelope proteins; which produces significant cross-reactivity.

Dengue virus has 4 subtypes, and infection with one subtype produces lifelong immunity to that subtype only.

To read this article in its entirety, please visit our website.

-- Burke A. Cunha, MD, Diane Johnson, MD, Brian McDermott, DO

This article was originally published in the April 2009 issue of The American Journal of Medicine.

Outcomes After Stroke: Risk of Recurrent Ischemic Stroke and Other Events

Stroke is a common and debilitating disease, and much is known about the incidence and risk factors for first stroke. Much less is known, however, about outcomes after stroke. The epidemiology of outcomes after stroke has been relatively less studied for several reasons, including the traditional study of populations in which rates of cardiac disease are higher than those of stroke, the heterogeneity of stroke, and the absence until recently of effective therapies. The importance of recurrent stroke, cardiac events, dementia, depression, and other vascular and nonvascular events will increase as the population ages and as more patients survive a first stroke. This article discusses the relative importance of recurrent stroke and other events after initial ischemic stroke or transient ischemic attack, and proven and potential risk factors for recurrent stroke. Based on growing evidence regarding the high rates of cardiovascular events after stroke, and the efficacy of statin therapy in reducing the risk of stroke as well as cardiac disease, it may be time to consider expanding the “coronary risk equivalent” category to include patients with stroke. Patients who have had a stroke are likely at high enough risk for subsequent events to warrant the same aggressive treatment, including statins and antihypertensive drugs, as would be given to patients with other forms of cardiovascular disease. Future clinical trials will better define the optimal management of patients after stroke.

To read this article in its entirety, please visit our website.

-- Mitchell S.V. Elkind, MD, MS

This article was originally published in a supplement to the April 2009 issue of The American Journal of Medicine.