Clinical Briefs
October 30, 2015 3 minutes read
Early Identification, Intensive Intervention for Diabetes Might Improve CV Outcomes
SOURCE: Herman WH, et al. Early detection and treatment of type 2 diabetes reduce cardiovascular morbidity and mortality: A simulation of the results of the Anglo-Danish-Dutch Study of Intensive Treatment in People With Screen-Detected Diabetes in Primary Care (ADDITION-Europe). Diabetes Care 2015;38:1449-1455.
The ADDITION-Europe trial enrolled adults (n = 120) whose diabetes had been detected through screening, and compared early intensive treatment (glucose, lipids, blood pressure, lifestyle) vs usual care. At the end of 5.3 years, there was a trend toward reduced cardiovascular (CV) outcomes that was not statistically significant. Nonetheless, these results were so encouraging that Herman et al performed a simulation model in which they compared potential outcomes in a much larger population extrapolated from the ADDITION-Europe trial data, as well as looked at a comparison population that was not screened (among whom one would anticipate significant delay in diagnosis and treatment).
When comparing usual care to intensive intervention, more subjects in the intensive intervention group were treated with statins, beta-blockers, and aspirin, and fewer persons smoked. When these same metrics were plugged into the Michigan Model for Type 2 Diabetes, and the potential number of participants substantially increased (to 6815), early detection through screening and intensive treatment was associated with a 29% relative risk reduction in CV events compared to an unscreened population diagnosed 6 years later and receiving usual care. Multifactorial trials in which blood pressure, lipids, weight, exercise, and glucose are concomitantly addressed have produced favorable CV risk reduction, but it becomes difficult to ascertain which component(s) of the multipronged intervention is most responsible for the beneficial outcomes.
Approaches to PTSD in Veterans
SOURCE: Polusny MA, et al. Mindfulness-based stress reduction for post-traumatic stress disorder among veterans: A randomized clinical trial. JAMA 2015;314:456-465.
PTSD among veterans deployed in recent years to Afghanistan and Iraq is commonplace and potentially debilitating. Unfortunately, 30-50% of PTSD sufferers who receive treatment with traditional psychological interventions do not enjoy significant improvement. Mindfulness-based stress reduction (MBSR) might be most simply described as “emotionally detached self-observation.” PTSD patients might be instructed to view the symptoms they are experiencing as a dispassionate external observer might, and instead of responding to their symptoms, simply take note of their symptoms in a non-judgmental fashion. Instead of continued focus on troubling or emotionally labile thoughts, patients can be taught to focus on breathing, muscle tone, and stretching.
In this clinical trial (n = 116), MBSR was compared with patient-centered group therapy, an intervention already demonstrated to provide positive outcomes in PTSD patients. Outcomes were measured at 3, 6, 9, and 17 weeks. MBSR provided better symptom improvement than patient-centered group therapy. On the other hand, the number of persons who no longer fulfilled diagnostic criteria for PTSD 2 months after conclusion (i.e., “remission” of PTSD) of the interventions was comparable in both groups. MBSR shows promise as a valuable intervention for PTSD patients.
Of course, PTSD may ultimately require combinations of psychological and/or lifestyle interventions, as well as pharmacotherapy.
Rosacea is Associated with Cardiovascular Disease
SOURCE: Hua TC, et al. Cardiovascular comorbidities in patients with rosacea: A nationwide case-control study from Taiwan. J Am Acad Dermatol 2015;73:249-254.
Recent innovations in pharmacotherapy specifically targeting immunologic pathways have led to the ability to offer remission of disorders like rheumatoid arthritis (RA) and psoriasis. To some degree, the promise of dramatic disease-altering therapies has led to a heightened awareness of these disorders among primary care clinicians. At the same time, increased detection and referral of RA and psoriasis has been accompanied by a new focus on the association between such disorders and cardiovascular (CV) adversities. Some experts have suggested RA be included in CV risk assessment scoring systems, since the impact of RA upon CV risk is similar to that of the other primary CV risk factors, such as dyslipidemia. The cause of rosacea remains unknown, but it is generally categorized as an inflammatory dermatosis, categorically similar to psoriasis.
Hua et al investigated the relationship between rosacea and cardiovascular disease using data from the National Health Insurance Research Database in Taiwan. Among the 33,553 patients identified with rosacea, there was an increased risk for hypertension, dyslipidemia, coronary artery disease, and peripheral arterial disease.
While the mechanism for the relationship between rosacea and CV disease is ill-defined at this point, one postulate is that systemic inflammation, which has been shown to alter the ability of lipoproteins to remove cholesterol from circulation, might be at least part of the explanation.
In this section: improving cardiovascular outcomes through early treatment of diabetes; re-thinking PTSD treatment in veterans; and a link between rosacea and cardiovascular disease.
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