Clinical Briefs in Primary Care
ACCORD-MIND: Memory in Diabetes
Source: Cukierman-Yaffe T, et al. Relationship between baseline glycemic control and cognitive function in individuals with type 2 diabetes and other cardiovascular risk factors: The action to control cardiovascular risk in diabetes-memory in diabetes (ACCORD-MIND) trial. Diabetes Care 2009;32:221-226.
The ACCORD trial has been newsworthy in the last several months primarily due to the early results of increased cardiovascular events associated with very tight glucose control. The ACCORD trial also has BP and lipid control arms, and includes a substudy on cognitive function called ACCORD-MIND: Memory in Diabetes. This cross-sectional study used a variety of cognitive tests to evaluate the relationship between glucose control and cognitive function.
In MIND (n = 2977), there was a linear relationship between baseline A1c and cognitive scores. For instance, on the Digital Symbol Substitution Test (DSST), for every 1% increase in A1c, there was a 1.75 point decreased DSST score; for comparison, in this age group each 1 year increase in age is associated with a 0.7 point DSST score decrease (and the aforementioned decrease had already been age-adjusted). Essentially, each 1% increase in A1c correlated to the same decline in cognitive function that would be seen (on average) with 2 years of aging.
Diabetes predisposes to cognitive decline, some of which is attributable to the increase risk of stroke in diabetics. Because subjects with stroke-related cognitive decline were excluded from this trial, the results suggest that hyperglycemia is negatively (inversely) related to cognitive function. Whether control of hyperglycemia has a favorable impact upon cognitive function remains to be determined.
Pulmonary embolism in acute COPD exacerbations
Source: Rizkallah J, et al. Prevalence of pulmonary embolism in acute exacerbations of COPD. Chest 2009;135:786-793.
In contrast to most of the top 10 causes of death in the United States, the COPD mortality rate (the 4th most common cause of death) is rising. The majority of COPD deaths happen during an acute COPD exacerbation, usually attributed to an infectious agent. Still, as many as 30% of exacerbations are of uncertain etiology.
The symptoms of acute pulmonary embolism and exacerbations of COPD have some overlap. Indeed, it is easy to explain away new dyspnea, cough, and worsening of pulmonary status by simply attributing symptoms to COPD exacerbation, which is, after all, the most common explanation. Recent studies have suggested, however, that pulmonary embolus may be an overlooked etiology for symptoms that are misattributed to COPD exacerbations.
Rizkallah et al performed a meta-analysis of trials in patients (n = 550) with apparent exacerbations of COPD who underwent CT scanning, pulmonary angiography, or both. They found that in patients who were hospitalized, as many as 25% were ultimately determined to have suffered pulmonary embolus; the prevalence in studies incorporating data from both inpatients and outpatients showed only a slightly lower prevalence (24%).
Although it is tempting to accept that new onset of dyspnea and cough in a patient with COPD is most likely due to an acute exacerbation, these data suggest a higher level of vigilance for pulmonary embolism in this population.
PLCO supports USPSTF recommendations
Source: Andriole GL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med2009;360:1310-1319.
The prostate, lung, colorectal, and Ovarian Cancer Screening Trial (PLCO) enrolled 76,693 men between 1993 and 2001, half of whom were assigned to receive annual PSA and DRE, and the other half of whom received usual care (USU). One of the endpoints of the trial was the mortality rate comparison between screened and USU men over 7-10 years of follow-up.
As might be intuitively obvious, the incidence of prostate cancer in the PSA/DRE group was somewhat higher (22% higher) than the USU group (116 vs 95 per 10,000), since men with an elevated screening PSA were referred for biopsy. Additionally, since PSA screening has become progressively more common as a component of usual care, one would not be surprised to learn that in this trial, 52% of men in the USU group had also received PSA screening.
The incidence of prostate cancer-related death per 10,000 subjects was very similar: 2 in the screening group vs 1.7 (USU). This slightly higher (but not statistically significantly different) prostate cancer-related mortality in the screened group suggests that PSA screening does not improve mortality over an interval as long as 10 years, giving credence to the recent USPSTF suggestion recommending against PSA screening in men older than age 75.
Balloon kyphoplasty for vertebral fractures
Source: Wardlaw D, et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): A randomised controlled trial. Lancet 2009;373:1016-1024.
Vertebral Fracture (VFX) is the most common complication of osteoporosis. Although often asymptomatic, VFX can cause pain, deformity, and loss of function. Until recently, treatment for VFX was generally conservative, consisting of pain medication, prevention of further osteoporosis, and physical therapy. Balloon kyphoplasty (BKY) is a minimally invasive technique that has been shown to restore function and relieve pain. The procedure is brief (typically < 1 hour), can be done on an inpatient or outpatient basis, and requires minimum down time post-intervention (often ≤ 48 hours).
Wardlaw et al performed a controlled trial comparing BKY with conservative care for patients with VFX (n = 266). The primary outcome was the physical function component of the SF-36 quality of life scale over a 1-month interval from the time of intervention.
In the BKY group, the SF-36 score improved by 7.2 points vs 2.0 points in the conservative care group. There was no difference in adverse events between the groups.
Kyphoplasty is a minimally invasive procedure that provides prompt relief of pain, restoration of structural integrity, and improvements in function, with very favorable tolerability. Clinicians should consider BKY as a viable option in patients with acute osteoporotic VFX.
Exercise improves QOL in CHF patients
Source: Flynn KE, et al. Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 2009;301:1451-1459.
Patients with Chronic Heart Failure (CHF) report progressively worse dyspnea with exercise, ranging from Class I NYHA (symptoms only present with strenuous exercise) to Class IV NYHA (symptoms present with any activity, even at rest). Such exertional dyspnea provides disincentive for exercise, and often leads to deconditioning, thereby worsening ability to participate fully in activities of daily living. In the past, there has been some concern that exercise for CHF patients might lead to increased adverse events.
Flynn et al randomized patients with systolic CHF (n = 2331), all of whom had an ejection fraction < 35%, to an intensive supervised exercise training program (EXE) vs usual care (USU). The intensive intervention consisted of supervised aerobic exercise training for 36 sessions, at 60-70% of heart rate reserve, three times weekly; subjects then underwent home-based training 5 times per week. The primary outcome was the score on the Kansas City Cardiomyopathy Questionnaire (KCCQ), a validated, heart failure-specific metric. KCCQ scores were obtained quarterly for 1 year, and then annually for an additional 3 years.
KCCQ scores were statistically superior in the EXE group as early as 3 months, and stayed that way through the remainder of the trial. Aerobic exercise training improves the quality of life and activity scores for persons with CHF.
CBT for anxiety in older adults
Source: Stanley MA, et al. Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: A randomized clinical trial. JAMA 2009;301:1460-1467.
The prevalence of generalized anxiety disorder (GAD) in older adults is as high as 11% in primary care settings. GAD can often be successfully treated with antidepressants and or benzodiazepines, but such interventions can also be associated with adverse effects and cost. The efficacy of cognitive behavior therapy (CBT) for late-life GAD has not been well established.
Stanley et al enrolled 134 adults (mean, age 70) with GAD in a randomized trial comparing CBT with usual care (USU) in a population of patients attending University of Texas Clinics in the greater Houston area. The primary outcomes of the study were intensity of worry and overall GAD severity.
The CBT intervention was administered in 10-12 sessions over 3 months. CBT intervention included multiple components: motivational interviewing, relaxation training, cognitive therapy, problem-solving skills, and sleep management. The USU group received biweekly phone calls to provide support, and offer consultation if symptoms worsened. At baseline, similar numbers of persons in both groups were receiving antidepressants (31-34%) and/or anxiolytics (17%).
For both primary and secondary outcomes, CBT was superior to USU. Benefits of CBT were seen as early as 3 months, and persisted at 15-month follow-up. CBT has been shown to provide outcomes improvement in older adults with GAD.
ACCORD-MIND: Memory in Diabetes; Pulmonary embolism in acute COPD exacerbations; PLCO supports USPSTF recommendations; Balloon kyphoplasty for vertebral fractures; Exercise improves QOL in CHF patients; CBT for anxiety in older adultsSubscribe Now for Access
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