Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Nonpolypoid Colorectal Neoplasms
The adenomatous polyp (ADP) is recognized as the primary predecessor of colon cancer (CCA), prompting management strategies to identify and remove ADP. Recently, it has been recognized that nonpolypoid neoplasms (NPN) can also evolve to CCA. Because of their nonpolypoid configuration (flat, slightly raised, or even slightly depressed), NPN are more difficult to identify by either traditional colonoscopy or CT methodology; hence, they are easily missed. Soetikno, et al assessed the prevalence of NPN in a cohort from the Veterans Administration Hospital in California who underwent elective colonoscopy (n=1,819).
Facility in the identification of NPN has not been part of the armamentarium of most traditionally-trained endoscopists in America. Hence, the investigators underwent training specifically directed towards NPN identification by Japanese endoscopists who are expert in this particular area (NPN has previously been described particularly in Japan).
From 1,819 colonoscopies, 42% of individuals had 1 or more neoplasms, of which 170 were NPN (9.35%). Although a minority of lesions, the NPN lesions were responsible for over half of the superficial carcinomas found. Recognition of the important pathologic contribution of NPN man- dates enhanced skills by endoscopists for their identification.
Soetikno RM, et al. JAMA. 2008;299(9):1027-1035.
Predictors of Disease Progression in Type 2 Diabetes
Although type 2 diabetes (2-DM) is generally a progressive disorder, there is great variation in rate of disease progression, allowing some patients to be managed with diet and exercise whereas others quickly require intensive lifestyle and pharmacotherapeutic regimens. There has been scant investigation into predictors of diabetes progression. To that end, patient data collected from 12 outpatient practices in eastern Massachusetts was utilized to study the factors associated with 2-DM progression. To be included in the data set (n=705), patients had to be diagnosed with 2-DM, but not yet using glucose-lowering medication. Progression was defined as either having to start pharmacotherapy or developing an A1c >7%.
At one year follow up, slightly over one-fourth of patients experienced disease progression. Age, weight, and baseline A1c were determined to be predictors after multivariate analysis.
For each 1-lb increase in weight, there was a 2% increase in risk of progression. Perhaps counterintuitively, for each decade of increased age, risk of progression was reduced 15%; this result supports recent observations that younger 2-DM patients tend to be more insulin deficient, compared to older individuals who are more often insulin resistant.
This information suggests that diabeticpatients who are younger and tend to gain weight are at greatest risk of disease progression, and may merit more intense lifestyle management.
Pani LN, et al. Diabetes Care. 2008;31:386-390.
A Relationship Between Antidepressants and Diabetes
In addition to the incidence of depression being 1.5-2 fold higher in diabetics than the general population, its morbid and mortal consequences are measurably greater. Data from the recently published Diabetes Prevention Program (DPP) allows investigation of the relationship between depression, antidepressant medications, or both, and diabetes.
A Beck Depression Inventory (BDI) was administered to 3,187 of the participants in the DPP at baseline and at each annual visit. All DPP enrollees also had impaired fasting glucose and impaired glucose tolerance but did not meet diagnostic criteria for type 2 diabetes.
Risk of progressing to diabetes was not associated with depression but was associated with use of antidepressants (greater than 2-fold increased hazard ratio). Analysis for specific types of antidepressant (eg, SSRI vs SNRI) did not demonstrate that any one class of antidepressant was more (or less) likely to be associated with progression to diabetes. The mechanism by which antidepressants induced this greater risk is unclear.
These data suggest that at the stage of prediabetes, since antidepressant use has been associated with disease pro- gression, maximization of non-pharmacotherapeutic intervention merits strong consideration.
Rubin RR, et al. Diabetes Care. 2008;31:420-426.
The adenomatous polyp (ADP) is recognized as the primary predecessor of colon cancer (CCA), prompting management strategies to identify and remove ADP.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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