Alethea N. Hill

Obstructive sleep apnea and dyslipidemia: evidence and underlying mechanism

IntroductionOver the past half century, evidence has been accumulating on the emergence of obstructive sleep apnea (OSA), the most prevalent sleep-disordered breathing, as a major risk factor for cardiovascular disease. A significant body of research has been focused on elucidating the complex interplay between OSA and cardiovascular risk factors, including dyslipidemia, obesity, hypertension, and diabetes mellitus that portend increased morbidity and mortality in susceptible individuals.ConclusionAlthough a clear causal relationship of OSA and dyslipidemia is yet to be demonstrated, there is increasing evidence that chronic intermittent hypoxia, a major component of OSA, is independently associated and possibly the root cause of the dyslipidemia via the generation of stearoyl-coenzyme A desaturase-1 and reactive oxygen species, peroxidation of lipids, and sympathetic system dysfunction. The aim of this review is to highlight the relationship between OSA and dyslipidemia in the development of atherosclerosis and present the pathophysiologic mechanisms linking its association to clinical disease. Issues relating to epidemiology, confounding factors, significant gaps in research and future directions are also discussed.

The risks of statin use in pregnancy: A systematic review

Statins are contraindicated in pregnancy; however, as women delay pregnancy and statin use increases the risk of statin exposure in pregnancy is likely to rise. In contrast to some early reports that statins are teratogenic, more recent observational studies have called into question the teratogenic risk of statins. Therefore, whether statins are associated with congenital anomalies or other pregnancy complications remains an important clinical question. This article provides an up-to-date systematic review on the risks of statins in pregnancy. We conducted a literature search to identify relevant English language studies related to statin exposure and pregnancy. Single case reports, animal studies, studies only published in abstract form, and non-English language studies were excluded. A total of 16 clinical studies were included in this systematic review. Although early uncontrolled case series reported congenital anomalies associated with statin use, more recent observational studies did not report an increased risk of congenital anomalies with statin exposure in pregnancy when compared to control groups or the prevalence of congenital anomalies in the general population. Our findings show no clear relationship of congenital anomalies with statin use in pregnancy, and our study supports the findings that statins are probably not teratogenic. However, until more information is available, statins should still be avoided in pregnancy.

A heart failure initiative to reduce the length of stay and readmission rates.

Purpose/Objectives: The purpose of this pilot was to improve multidisciplinary coordination of care and patient education and foster self-management behaviors. The primary and secondary outcomes achieved from this pilot were to decrease the 30-day readmission rate and heart failure length of stay. Primary Practice Site: The primary practice site was an inpatient medical–surgical nursing unit. Finding and Conclusions: The length of stay decreased from 6.05% to 4.42% for heart failure diagnostic-related group 291 as a result of utilizing the model. The length of stay decreased from 3.9% to 3.09%, which was also less than the national rate of 3.8036% for diagnostic-related group 292. In addition, the readmission rate decreased from 23.1% prior to January 2013 to 12.9%. Implementation of standards of care coordination can decrease length of stay, readmission rate, and improve self-management. Implications for Case Management Practice: Implementation of evidence-based heart failure guidelines, improved interdisciplinary coordination of care, patient education, self-management skills, and transitional care at the time of discharge improved overall heart failure outcome measures. Utilizing the longitudinal model of care to transition patients to home aided in evaluating social support, resource allocation and utilization, access to care postdischarge, and interdisciplinary coordination of care. The collaboration between disciplines improved continuity of care, patient compliance to their discharge regimen, and adequate discharge follow-up.

Physical activity in diabetes: Is any better than none?

In the United States, 13% of adults have diabetes and an additional 30% are at high risk of developing diabetes (Cowie et al., 2009). Because diabetes increases the risk of vascular morbidity and mortality (The Emerging Risk Factors Collaboration, 2010), lifestyle modification and pharmacologic therapy are recommended (American Diabetes Association, 2013; Inzucchi et al., 2012) for clinical management and to prevent complications. In this issue of the Journal, Brown and colleagues (2014) investigated the association of lifestyle modification and pharmacologic therapy for type 2 diabetes mellitus (T2DM) with allcause and cardiovascular disease (CVD) mortality. Using data for adults ages≥40 years, the authors investigated whether physical activity (PA) (defined as≥1 PAweekly versus no PAweekly), pharmacologic therapy use (defined as treated with insulin or oral hypoglycemic medications versus not treated with insulin or oral hypoglycemic medications), and glycemic control (defined as HbA1c b 7.0% versus HbA1c ≥ 7%) were associatedwith risk ofmortality. The authors classified participantswith T2DM as 1) treated and controlled; 2) untreated and controlled; 3) treated and uncontrolled; 4) untreated and uncontrolled and further stratified their analyses by PA within each classification. The primary finding was that compared with individuals with T2DM who were physically active, treated, and controlled, individuals with T2DM who were physically inactive within each classification had an increased risk of all-cause and CVD mortality. Additionally, the mortality risk for individuals with T2DM who were physically active, treated, and controlled was similar to the mortality risk for those who did not have T2DM who were or were not physically active. The findings by Brown et al. suggest that PA as little as once weekly, which is less than the current PA recommendation, may yield health benefits for individuals with T2DMregardless of glycemic control or pharmacologic therapy use. The inverse association of PA with mortality risk among individuals with T2DM has been reported previously. Two meta-analyses reported PA decreased the risk of mortality among individuals with T2DM, with those in the highest PA category having a 40% lower risk of all-cause (Kodama et al., 2013; Sluik et al., 2012) and CVD mortality (Sluik et al., 2012) than those in the lowest PA category. Furthermore, a metaanalysis of the effect of PA on glycemic control among individuals with T2DM found that PA interventions, compared with no PA, resulted in lower HbA1c despite no significant weight change (Boulé, Haddad, Kenny, Wells, & Sigal, 2001). Individuals with T2DM are often overweight or obese, therefore many intervention studies have focused onweight reduction, with PA often included as part of the intervention, and have been mostly short-term (Norris et al., 2005). However, one multi-center randomized controlled trial, the Action for Health in Diabetes Study (Look AHEAD), evaluated the long-term effect of an

Changes in the treatment of inpatient hyperglycemia: What every nurse practitioner should know about the 2012 Standards of Care

Purpose: To provide nurse practitioners (NPs) with a review of the 2012 Standards of Care for the management of hospitalized patients who are hyperglycemic. Data sources: The 2012 American Diabetes Associations (ADA) Standards of Care for the treatment of inpatient hyperglycemia and selected evidence‐based articles. Conclusions: Because hyperglycemia occurs at alarming rates in the inpatient setting when hyperglycemia is not controlled, there is a great impact on acute and even chronic conditions. These complications will lead to increased healthcare costs. Implications for practice: It is essential that NPs who care for hospitalized, hyperglycemic patients are aware of the 2012 ADA Standards of Care.

Diagnosing diabetes with A1C: implications and considerations for measurement and surrogate markers.

According to the CDC, approximately 23.6 million people (7.8% of the population) have diabetes, and an additional 5.7 million people remain undiagnosed.1 In addition, the effects of uncontrolled glucose levels is directly correlated with diabetes-related complications and morbidity.2 The number of d

Changes in the treatment of inpatient hyperglycemia

Purpose: To provide nurse practitioners (NPs) with a review of the 2012 Standards of Care for the management of hospitalized patients who are hyperglycemic. Data sources: The 2012 American Diabetes Associations (ADA) Standards of Care for the treatment of inpatient hyperglycemia and selected evidence‐based articles. Conclusions: Because hyperglycemia occurs at alarming rates in the inpatient setting when hyperglycemia is not controlled, there is a great impact on acute and even chronic conditions. These complications will lead to increased healthcare costs. Implications for practice: It is essential that NPs who care for hospitalized, hyperglycemic patients are aware of the 2012 ADA Standards of Care.

Changes in the treatment of inpatient hyperglycemia: What every nurse practitioner should know about the 2012 Standards of Care: Changes in the treatment of inpatient hyperglycemia

Purpose: To provide nurse practitioners (NPs) with a review of the 2012 Standards of Care for the management of hospitalized patients who are hyperglycemic. Data sources: The 2012 American Diabetes Associations (ADA) Standards of Care for the treatment of inpatient hyperglycemia and selected evidence‐based articles. Conclusions: Because hyperglycemia occurs at alarming rates in the inpatient setting when hyperglycemia is not controlled, there is a great impact on acute and even chronic conditions. These complications will lead to increased healthcare costs. Implications for practice: It is essential that NPs who care for hospitalized, hyperglycemic patients are aware of the 2012 ADA Standards of Care.