PRE-DIABETES IS IMPORTANT TOO!

Prediabetes Signals CAD Risk
By Ed Susman, Contributing Writer, MedPage Today
Published: May 03, 2013
Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman
School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA,
BSN, RN, Nurse Planner
PHOENIX – Individuals with impaired fasting
glucose levels – often called prediabetics –
appear to have similar cardiovascular risk
factors as patients with diabetes, researchers
reported here.
In the study, about 36% of patients with
impaired fasting glucose had coronary artery
disease compared with 42% of patients with
diabetes and 21% of patients with normal
blood glucose said Harith Al-Shuwaykh, MD, a
resident in internal medicine at Crittenton
Hospital Medical Center, Wayne State
University, Detroit.
Those findings, which were based on a review
of 86 patients who underwent elective
percutaneous coronary intervention, were
presented at the annual meeting of the
American Association of Clinical
Endocrinologists.
Likewise 37% of patients with impaired fasting
glucose had hyperlipidemia compared with
38% of patients with diabetes and 24% of
patients with normal blood glucose.
Al-Shuwaykh told MedPage Today the results
indicate that early intervention among the
prediabetics may be warranted.
"It is recommended to identify and treat
impaired fasting glucose patients early since
impaired fasting glucose patients' distribution
in coronary artery disease is comparable to
diabetes mellitus," he said at his poster presentation. He noted that both impaired fasting glucose
patients and diabetes patients had nearly double the distribution of hypertension and high
cholesterol when compared with normal fasting glucose patients.
He said his results also suggest a need to screen patients with a family history of coronary artery
diseases for impaired fasting glucose and diabetes since 40% of the patients with impaired fasting
glucose has a family history of heart disease and 33% of those with diabetes had a family history of
heart disease.
"In our study we tried to find the impact and contribution of impaired fasting glucose as a risk factor
for coronary artery disease in a population of patients who already have coronary disease," AlShuwaykh explained. "We found that a large percentage of these people do have diabetes but the
people with impaired glucose levels have similar risk profiles."
The chart review revealed that 19 of the individuals had normal fasting glucose levels, that is
fasting blood glues below 100 mg/dL; 30 patients had impaired fasting blood glucose levels (100-
125 mg/dL) and 37 patients were diabetic with fasting blood glucose levels above 125 mg/dL.
"This is a very critical study," Richard Dolinar, MD, a private practice physician in Phoenix and a
member of the legislative and regulatory committee of the AACE, told MedPage Today.
"What it showed was that even though the glucose levels were not at the level of diabetes there
was an impact on the body in regards to hypertension and lipids, etc. It shows there, indeed, is an
abnormality there. The fasting glucose below 100 mg/dL is normal. Fasting glucose above 126
mg/dL is diabetes. But that in between area is significant and that is what this study shows."5/8/13 Prediabetes Signals CAD Risk
www.medpagetoday.com/MeetingCoverage/AACE/38836 2/2
Al-Shuwayhk and Dolinar had no disclosures.
Al-Shuwaykh said, "Our study emphasizes the role of the primary care physician and the
endocrinologist in how to deal with this problem. We have to intervene early and create an
educational program to prevent impaired fasting glucose and if it is diagnosed we should act on it
promptly.
"Usually what we tell the patient is to exercise, diet, lose weight and most of those patients will try
but it is really difficult for them and a lot of them will ignore the problem and they come later with
coronary artery disease. So our recommendation is to treat those patients and to follow with
exercise for a goal of taking them out of treatment when they really commit to a diet and exercise
program."
"Studies like this impact pharmacologic intervention with impaired fasting glucose," Dolinar said.
"Historically we have told our patients to diet and exercise and that is a good idea, but it just
doesn't work. Fortunately we have pharmaceutical interventions so that when we have patients with
Type 2 diabetes we can intervene with a variety of medications.
"I think that in the case of prediabetes we should consider intervening pharmacologically because
there are abnormalities there that we could treat. It would be off label but I think it would be
important to look at that and get more studies and study this further," he said.
Al-Shuwaykh said there were limitations to his study, particularly the retrospective design and the

PROSTATE

ACP Guidance on PSA Screening Calls for Risk-Benefit Discussion, Clear Patient Preference

By Matt Brown

Posted: 4/23/2013, 12:05 p.m. -- In recently published clinical guidance on prostate cancer screening, the American College of Physicians (ACP) calls for physicians to discuss "the limited potential benefits and substantial harms of screening for prostate cancer" with patients between the ages of 50 and 69. The guidance also encourages doctors to perform screening only if a patient expresses a clear preference to do so.

Human prostate specific antigen (PSA/KLK3) with bound substrate from complex with antibody. (Source: E.A.S./CC-BY-SA-3.0)

According to the ACP guidance, any decision to screen using the prostate-specific antigen (PSA) test should be based on

• the patient's risk for prostate cancer,
• a discussion of the benefits and harms of screening,
• the patient's general health and life expectancy, and
• patient preferences.

The ACP further recommends that PSA screening not be performed in average-risk men who are younger than 50 or older than 69, as well as in those who have a life expectancy of less than 10-15 years. 

It's worth noting that the ACP guidance statement was derived from an appraisal of available guidelines on screening for prostate cancer. The four guidelines selected for review were those developed by the American College of Preventive Medicine, the American Cancer Society, the American Urological Association, and the U.S. Preventive Services Task Force (USPSTF).

STORY HIGHLIGHTS

• In its new recommendation, the American College of Physicians calls for physicians to discuss "the limited benefits and substantial harms of the prostate-specific antigen (PSA) test" with patients between the ages of 50 and 69 and encourages doctors to perform screening only if the patient expresses a clear preference to do the test.
• The AAFP and U.S. Preventive Services Task Force recommend against performing PSA screening in asymptomatic men, regardless of age.
• Two family physician experts agree that further research could help identify any subset of men who might benefit from PSA screening.

NEW GUIDANCE LARGELY ALIGNS WITH AAFP/USPSTF RECOMMENDATIONS

Although the ACP guidance, which was published April 9 in theAnnals of Internal Medicine, does not flatly contradict the AAFP and USPSTF recommendations against performing PSA screening in asymptomatic men regardless of age, some differences in emphasis exist. 

In its 2012 recommendation statement, the USPSTF acknowledged that PSA screening is commonly used in practice and that some men will continue to request screening and some physicians will continue to offer it.

"The decision to initiate or continue PSA screening should reflect an explicit understanding of the possible benefits and harms and respect patients' preferences. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision-making that enables an informed choice by patients," say the USPSTF guidelines.

According to USPSTF member Mark Ebell, M.D., of Athens, Ga., "The ACP assessment of the data is very similar to that of the USPSTF: The benefits (of PSA screening) are, at best, small, and the harms are likely to be moderate. "Of course, some men may still choose to be screened, but I hope they only do so after a careful discussion with their family physician so they understand the potential harms."

Gretchen Dickson, M.D., a family physician and assistant professor of family and community medicine at the University of Kansas School of Medicine, Wichita, said it can be difficult -- for both physicians and their patients -- to wade through sometimes conflicting clinical advice.

"If you follow the USPSTF, you would rarely screen anyone, whereas the American Urological Association suggests starting to offer screening to men at age 40," Dickson said. "Not only is that confusing to physicians, but patients may get mixed messages about what the 'right' answer is for them. 

"And, as the recommendations change, that further compounds patient confusion."

Dickson said she appreciates the fact that the ACP guidance recognizes that the PSA test offers limited benefits and substantial harms and points out that screening should not occur in men younger than 50 or older than 69 or in those with limited life expectancy.

"In general, I recommend against PSA-based prostate cancer screening for my male patients in line with the recommendations of the USPSTF," she said. "That recommendation usually comes after a long conversation, though, about what we know and don't know about prostate cancer screening. Given the current evidence, screening seems to do more harm than good for most patients."

FURTHER RESEARCH NEEDED TO FILL KNOWLEDGE GAPS

The problem, Dickson said, surrounds the knowledge gaps that exist relative to prostate cancer screening. 

"Many of the studies that are used to formulate the prostate cancer screening guidelines were done predominantly in Caucasian populations, yet African American men have among the highest risk of prostate cancer," she said. "Perhaps our screening recommendations would change if we had more high-quality evidence from studies involving more racially diverse subjects. 

"As we learn more about PSA velocity, density, free PSA and other tests, we may find that screening is warranted for specific populations, but, today's best evidence suggests that screening may do more harm than good for most men."

Ebell agreed that more research would almost certainly help clear the fog a bit.

"There is certainly a need for more research in black men," he said. "But the recent PIVOT (Prostate Cancer Intervention Versus Observation Trial) trial that compared early treatment with active surveillance found no difference in the treatment outcomes for black men (30 percent of those studied) compared with other participants."

Of course, said Dickson, even after explaining the risks to her patients, she does have some men who choose to be screened.

"The difference is that ordering a PSA test isn't something that I just tack on to 'routine labs' for my male patients. We talk about the test a lot before we decide that PSA testing is right for them," she said. "It isn't a short visit, but the conversation reassures me that I've given them all the tools to make their decision.

"The ACP statement acknowledges that by the best evidence we have today, it appears the risks outweigh the benefits of PSA testing for most men," she said. "But ultimately, the physician and the patient must have a conversation and decide if (that patient) is a man who doesn't fit into that 'most men' category."

FULL SCHEDULE OF VACCINES ISN'T TIED TO AUTISM RISK

Full vaccine schedule safe for kids, no link to autism
Liz Szabo, USATODAY 12:26a.m. EDT March 29, 2013
A new study is the latest research failing to find a connection between autism and vaccines.
At least 10% of parents of young children skip or delay routine vaccinations, often out of concern that kids
are getting "too many shots, too soon."
A new study finds that children who receive the full schedule of vaccinations have no increased risk of autism.
"This is a very important and reassuring study," says Geraldine Dawson, chief science officer at Autism
Speaks, who wasn't involved in the new paper. "This study shows definitively that there is no connection
between the number of vaccines that children receive in childhood, or the number of vaccines that children
receive in one day, and autism."
The study, published today in the Journal of Pediatrics, is the latest of more than 20 studies showing no connection between autism and vaccines,
given either individually or as part of the standard schedule. The paper is the first to consider not just the number of vaccines, but a child's total
exposure to the substances inside vaccines that trigger an immune response.
Study authors say they sought to address the fear that multiple vaccines are "overwhelming" children's immune system, possibly contributing to longterm problems. Twenty years ago, children were vaccinated against nine diseases. Today, they're vaccinated against 14, according to the Centers for
Disease Control and Prevention, which funded the study.
Though kids get more needle sticks, the next-generation vaccines they receive are easier on the immune system than those used two decades ago,
says Frank DeStefano, lead author of the new paper and director of the Immunization Safety Office at the Centers for Disease Control and Prevention.
That's because modern vaccines are more sophisticated, using just a few critical particles — called antigens — to stimulate the immune system,
DeStefano says. These antigens, found on the surfaces of bacteria and viruses, spur the body to make antibodies, which block future infections.
For example, an older version of the pertussis (whooping cough) vaccine, used until the late 1990s, was made using an entire, killed bacteria. That
vaccine, called DTP, exposed the body to more than 3,000 antigens.
A newer, streamlined version, called DtaP, uses only the four to six antigens critical to producing immunity, DeStefano says.
Because of these sorts of improvements, fully vaccinated 2-year-olds are exposed to a total of 315 antigens, the study says.
That's a drop in the bucket compared with the billions of microbes — from bacteria to yeast — that babies encounter in their first hours of life.
The new research confirms the findings of a 2010 study in Pediatrics, which compared babies who received all vaccines on time in the first year of life
with those who skipped or delayed their shot. That research found no neuropsychological differences, such as stuttering, facial tics or lower scores on
IQ tests.
"A lot of parents are concerned about the number of 'owies' that children get," says Michael Smith, an author of the 2010 study and pediatric infectious
disease specialist at the University of Louisville School of Medicine.
"But there's no benefit to delaying vaccines," says Smith, who wasn't involved in the new study. "When you delay your child's vaccines, you put them at
risk."
STORY: Why don't teens get shots for HPV and other diseases? (http://www.usatoday.com/story/news/nation/2013/03/18/hpv-teenvaccinations/1987947/)
Myths about autism and vaccines have persisted, in spite of the scientific evidence, partly because researchers don't really know what causes autism,
Dawson says. "Until we conduct the research to answer the questions about autism's causes and risk factors, parents will continue to have questions,"
she says.
(Photo: Toby Talbot, AP)Research increasingly suggests that many of the underlying changes that cause autism take place before birth, and even before conception. Although
parents often notice symptoms of autism only after a child is 12 to 18 months old, research by Dawson and others picked up subtle changes — in eye
gaze or even brain patterns — as early as 6 months.
Doubts about vaccines have led to low vaccination rates in some communities, which have fueled flare-ups of once-forgotten diseases such as
whooping cough, measles and mumps, Smith says. "If someone gets on a plane from Europe or India where there is measles, then we have measles
again," Smith says.
The CDC reported Thursday that the USA had three cases last year of congenital rubella syndrome, an often fatal condition that afflicts the newborns
of mothers who contract rubella, or German measles, while pregnant. Affected babies often suffer from a number of painful and life-threatening
problems, such as heart defects, deafness, cataracts and mental retardation.
Vaccination has eliminated person-to-person spread of rubella in the Western Hemisphere. All three of the mothers last year were from Africa, where
rubella still circulates. One of the babies died.
Though some parents may never believe vaccines are safe, the new study will probably reassure many others, says Karen Ernst of Voices for
Vaccines, a group of parents and other vaccine advocates.
"Those who truly benefit from this article are the children of future parents," Ernst says. "These future parents will have more confidence in vaccinating
their children on time. It is the job of parent-advocates like our members to speak up and make sure news about articles like this gets out."

PROSTATE SCREENING

Doctors group questions prostate cancer screening

Mon, Apr 8 2013

By Genevra Pittman

NEW YORK (Reuters Health) - The American College of Physicians (ACP) became the latest group to ask doctors to be clear about the limited benefits and "substantial harms" of prostate cancer screening before offering their male patients a prostate-specific antigen (PSA) test.

The ACP's guidance statement, published Monday in the Annals of Internal Medicine, also explicitly recommends against screening men younger than 50, older than 69 or with less than 10 to 15 years to live.

Men in their 50s and 60s may weigh the potential benefits and harms of PSA testing differently, which is why the idea of shared decision-making between patients and their doctors is so critical, said the ACP's Dr. Amir Qaseem.

"It's important to sit down and explain everything to the patient and then if someone wants to be screened, that's okay," Qaseem told Reuters Health.

The concern with screening is that PSA tests catch some cancers that never would have affected a man's life because they are so small and slow-growing - yet treatment can cause side effects such as incontinence and impotence.

And there's still disagreement about whether regular screening saves a significant number of lives.

Organizations including the U.S. Preventive Services Task Force (USPSTF), a government-backed panel, have come out against PSA testing for average-risk men in recent years - and created controversy in the process (see Reuters Health story of April 25, 2012 here:).

The American Urological Association, on the other hand, says the decision to undergo PSA testing should be individualized. Last year, the group criticized the USPSTF for doing "a great disservice by disparaging what is now the only widely available test for prostate cancer."

"The AUA agrees that the decision to test for prostate cancer be made in the context of a detailed conversation between a man and his physician, and it is important to know what guidance is being provided to the medical community by leading medical groups," a representative for that organization told Reuters Health in an email on Monday.

The representative declined to comment specifically on the ACP's statement, adding that AUA will be releasing its own new guidelines shortly.

In the United States, about 239,000 men are expected to be diagnosed with prostate cancer in 2013, but far fewer - less than 30,000 - will die of it, according to the American Cancer Society.

In its statement, the ACP said that among men ages 50 to 69, doctors should base their screening decision on the patient's risk for prostate cancer, his general health and preferences and on a discussion of the potential benefits and harms of screening. Doctors should not test men "who do not express a clear preference for screening," the group added.

"There may be situations where patients don't really know what to do or may not be able to decide, and in that case, you don't screen," Qaseem said.

"The probability of somebody dying from prostate cancer is very low," he added. "There's a small potential benefit (to screening)… and the harms are very significant."

Dr. David Bronson, president of ACP, agreed that current PSA testing has limitations. Several refined prostate cancer tests are coming to market soon, the New York Times reported late last month:.

"This is a great opportunity for innovation," Bronson told Reuters Health.

"We need a new refined testing approach for this disease that will yield better, more accurate diagnoses."

SOURCE: bit.ly/MnBiCA Annals of Internal Medicine, online April 8, 2013.