Russell D. White

Patient empowerment and optimal glycemic control

Abstract Objective: This review updates the clinician on strategies of insulin use and educational approaches to empower their patients to use insulin correctly in self-management treatment plans. Design and methods: A PubMed literature search was conducted to identify peer-reviewed clinical trials published in English in the last 10 years. Search terms used were ‘glycemic control’, ‘insulin’, and ‘type 2 diabetes’. An additional search to include the terms ‘patient empowerment’ and ‘self-management’ was also conducted. Some articles relevant to this review may not have been identified using these terms. Oral antidiabetes agents in conjunction with insulin are not addressed. Results: A total of 562 articles were initially identified. Papers that did not provide data pertinent to the efficacy and tolerance of insulin types for treatment of type 2 diabetes mellitus (T2DM) were excluded. Based on methodology, results, and clinical implications, 12 clinical trials were included for discussion in this review. Conclusions: Patients with T2DM who are empowered with knowledge about their disease and treatment can take an active role in their diabetes care, and therefore, are more likely to achieve blood glucose and A1C goals, which can slow progression of their disease and the onset of complications. Although concentrating solely on medical information and physiological facts does not guarantee patient empowerment and self-management, educational strategies such as interactive teaching, problem solving and individualized education can have a positive impact. Insulin titration algorithms can empower patients to manage their therapy, and such algorithms are simple to use for patients treated with insulin analogs. As patients with T2DM become empowered by knowledge and gain more control of their disease, their physicians must then serve as their advisors rather than as their directors or prescribers.

Performing the exercise test.

With proper training, exercise testing is a useful diagnostic procedure for the primary care physician in the outpatient as well as the inpatient setting. By careful pretest evaluation, one is able to study patients safely and to obtain both diagnostic and prognostic information concerning the risk for cardiovascular disease.

Attention deficit hyperactivity disorder and athletes

Context: Attention deficit hyperactivity disorder (ADHD) is common in the general population, and many individuals with this condition participate in sports activity at all competition levels. Evidence Acquisition: Related studies were selected through literature searches of PubMed, MEDLINE, and Cochrane databases for the years 1991 to 2011. Key search terms were ADD, ADHD, sports, athletes, athletics, guidelines, NCAA, WADA, IOC, college, concussion, diagnosis, management, treatment, evaluation, return-to-play, pharmacotherapy, adult, adolescent, student, screening, injury, risk, neuropsychiatry, TBI, traumatic brain injury, and epidemiology. Study Design: Literature review. Level of Evidence: Level 4. Results: ADHD usually has an early onset, with delayed diagnosis in some patients due to heterogeneous presentations. Suspected cases can be evaluated with available diagnostic tools and confirmed clinically. Athletes with ADHD may participate at all competition levels. Conclusion: Athletes with ADHD are able to participate at all competition levels by following published guidelines and requirements. Exercise benefits many athletes with ADHD. The relationship between ADHD and concussion syndromes is currently under investigation.

The treat-to-target A1C approach to control type 2 diabetes and prevent complications

Before initiating insulin therapy, clinicians often wait until oral antidiabetic agents fail to adequately reduce glycosylated hemoglobin (A1C) levels and control hyperglycemia in patients with type 2 diabetes. Long-term, randomized clinical trials demonstrate that reducing A1C to close to normal decreases rates of microvascular complications and can also reduce macrovascular complications. Insulin regimens that treat to target A1C levels may achieve greater control of hyperglycemia. Various randomized trials have assessed the efficacy and safety of initiating insulin therapy with human insulins and insulin analogs in patients with type 2 diabetes whose condition is inadequately controlled with oral antidiabetics. These studies assessed different regimens, including basal and premixed insulins, for their ability to reach target A1C goals and provided evidence-based protocols for the initiation and systematic dosage titration of insulin therapy in patients with type 2 diabetes. Examples of how to initiate and intensify insulin therapy to achieve target A1C goals based on these protocols are presented.

Diabetes in the Competitive Athlete

Diabetes mellitus is the most common group of metabolic diseases and is characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Most patients with diabetes are type 2 (90%); the remaining patients have type 1 disease. Athletes with diabetes range from the athlete participating in various youth sports to the competitive Olympic athlete and present a significant challenge to themselves and the medical staff who care for them on a daily basis. Each sport and the type of exercise have their own effects on diabetes management with numerous factors that significantly affect glucose levels, including stress, level of hydration, the rate of glycogenolysis and gluconeogenesis, and the secretion of counter-regulatory hormones. This article provides a general overview of diabetes mellitus, the effects of exercise on glucose levels, and a detailed review of the potential complications encountered in the management of diabetes in the athlete.

Exercise testing in special populations: athletes, women, and the elderly.

Exercise testing in special populations such as athletes, women, and the elderly requires additional considerations from the clinician. Different protocols, as well as special accommodations, may be necessary for performing the test. Symptomatic athletes may have a number of cardiac conditions that lead to ischemic changes on the exercise test. Asymptomatic athletes often use serial exercise testing to evaluate the efficacy of training programs. For women and the elderly, assessment of risk factors and evaluation of symptoms are important considerations before performing the exercise test. Negative exercise test findings suggest a low risk for future cardiovascular events. Positive exercise test findings must be interpreted in light of the individuals pre-test probability. Assessment of the needs of these patients allows the clinician to tailor the exercise test to produce useful information.

Testing Special Populations

Much of the evidence for recommendations regarding electrocardiogram (ECG) treadmill stress testing has come from studies involving middle-aged men. Special consideration must be given when deciding who, when and how to screen for cardiovascular disease in patients who fall outside of this category. There is less data on noninvasive testing in women, older adults and people with diabetes, although this issue is being recognized and addressed through recent studies and literature. The previous conception that coronary artery disease is only a disease found in men is quickly being replaced. Clinicians are recognizing that different standards must be used for identification of patients at risk, testing protocols and test interpretation. This chapter addresses the use of ECG treadmill stress testing in women, the elderly and persons with diabetes.

Stratifying Symptomatic Patients Using the Exercise Test and Other Tools

Risk stratification of patients with chest pain occurs daily by physicians in the primary care setting. When patients present in the office with recent or new-onset chest pain, the physician must determine the appropriate evaluation. Does this pain represent coronary artery disease or is the pain due to some other cause? When a patient with pre-existing risk factors for coronary artery disease presents with typical angina symptoms, the physician must recommend appropriate evaluation. Finally, how does one manage the patient in the emergency department with chest pain? All of these clinical situations presenting to the primary care physician require assessment through the performance of specific evaluations in the proper setting and time period. Some patients can be evaluated over hours or days. Other patients require immediate consultation with a cardiologist. This chapter first reviews the concept of risk stratification, definitions of coronary disease and looks at multiple stratification tools. Second, these tools are discussed as they are applied to stratifying patients with chest pain. The final section presents multiple case studies illustrating the use of these tools in the approach to the patient with chest pain. Risk stratification involves determining the likelihood of coronary artery disease being present (diagnosis) and the future risk of cardiac events for the patient (prognosis). This process may require careful objective testing while at other times subjective intuitive evaluation based on experience and statistical data occurs. When a 62-year-old man with multiple cardiac risk factors (positive family history of coronary artery disease, personal history of smoking, hypertension, type 2 diabetes mellitus and hyperlipidemia) presents with a pressure discomfort in the anterior chest precipitated by exertion and relieved with rest, one promptly places this patient at a high likelihood for coronary artery disease. This immediate determination from the history that coronary artery disease is probably present occurs before the patient is examined and with no objective test results. Other clinical presentations may require thorough evaluation and testing for subsequent risk stratification.

Performance of the Exercise Test

Each year, over 1 million Americans experience a nonfatal or fatal myocardial infarction or sudden death from coronary heart disease (CHD) [1]. Unfortunately, death or myocardial infarction is the first symptom in 55% of patients with coronary artery disease [2] and is usually due to dislodgement of a plaque causing acute coronary occlusion. However, about 30% of these patients present with ischemia and have concurrent chest pain. In these individuals, exercise treadmill testing is a practical and the most commonly performed test to identify or confirm the presence of latent coronary artery disease [2]. In addition, an abnormal test has been shown to have definite predictive value. It is well known that when symptoms of typical angina are present, coronary disease can be predicted with considerable reliability. Even when there is no history of pain, there is still a strong possibility of significant coronary disease in patients with specific risk factors. Also, the reliability of the test in asymptomatic patients is improved when testing patients with a higher prevalence of the disease. Exercise testing may also be used to measure functional capacity, assess the patient’s prognosis in coronary artery disease, and evaluate the patient’s treatment for hypertension, certain arrhythmias, angina, and congestive heart failure. It can be beneficial for patients who will be involved in exercise rehabilitative programs. It may be useful for predicting mortality risk among patients who plan to start an exercise program, whose job affects public safety (airline pilot), or who have specific medical conditions (diabetes or chronic renal insufficiency). The inherent accuracy of the test is defined by the sensitivity and specificity. The results of the test when applied to an individual depend on the prevalence of disease in the population to which the patient belongs. So, the two most important factors in the analysis of patients undergoing stress testing are the pre-test prevalence of disease and the sensitivity and specificity of the test. Various types of chest pain affect the probability of disease in each patient. By dividing the patients into one