Target Blood Pressure in Patients with Diabetes: Asian Perspective

Recently, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure (BP) trial enrolled 4733 participants with type 2 diabetes and randomized them to a target systolic blood pressure (SBP) of less than 120 mm Hg or 140 mm Hg. Despite the significant difference in the achieved SBP, there was no significant difference in the incidence of primary outcomes. Based on this evidence, the target SBP for diabetics has been revised in the majority of major guidelines. However, there is a steeper association between SBP and stroke in Asians than other ethnicities, with stroke being the leading cause of cardiovascular mortality. This suggests that target BP in the Asian region should be tailored towards prevention of stroke. In the ACCORD study, the intensive BP treatment was associated with significant reductions in both total stroke and non-fatal stroke. The results from the ACCORD study are supported by a subgroup analysis from the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) study, which showed that, in diabetic patients, the risk of stroke continues to decrease to a SBP value of 115 mm Hg with no evidence of J curve. As diabetes is highly associated with underlying coronary artery disease, there is a justified concern for adverse effects resulting from too much lowering of BP. In a post hoc analysis of 6400 diabetic subjects enrolled in the International Verapamil SR-Trandolapril (INVEST) study, subjects with SBP of less than 110 mm Hg were associated with a significant increase in all-cause mortality. In the ONTARGET study, at any levels of achieved SBP, diastolic blood pressure (DBP) below 67 mm Hg was associated with increased risk for cardiovascular outcomes. As such, a prudent approach would be to target a SBP of 130–140 mm Hg and DBP of above 60 mm Hg in diabetics with coronary artery disease. In conclusion, hypertension, in association with diabetes, has been found to be significantly correlated with an elevated risk for cardiovascular events. As the association between stroke and BP is stronger in Asians, compared to other ethnicities, consideration should be given for a target BP of 130/80 mm Hg in Asians.

Suicidal ideation in medical students: who is at risk?

<p><b>INTRODUCTION</b>Suicide is one of the most tragic problems medical schools are facing today. It is an issue that has not escaped medical schools in either developing or developed nations. To combat this trend, medical educators require efficient and effective strategies for the immediate identification of students who are at an elevated risk of harming themselves.</p><p><b>MATERIALS AND METHODS</b>National Yang Ming University medical students were surveyed on various demographic, academic, personal, and extracurricular subjects as well as assessed for suicidal ideation. In addition, students completed the Chinese Health Questionnaire (CHQ, a translated and modified version of the General Health Questionnaire, GHQ), and the Taiwanese Depression Questionnaire (TDQ, a translated and modified version of the Center for Epidemiologic Studies' Depression Scale, CES-D).</p><p><b>RESULTS</b>The rate of suicidal ideation was significantly higher in second year students as opposed to fi rst year students (P <0.01). Students of lower socioeconomic status (P = 0.04), with non-inflammatory joint pain (P = 0.02), with headache (P = 0.047), with sleep disorders (P = 0.04), who scored as depressed on the TDQ (P <0.01), and/or who scored abnormally on the CHQ (P <0.01) were all significantly more likely to have experienced suicidal ideation.</p><p><b>CONCLUSION</b>A number of groups at high risk for suicidal ideation, and thus in greater need of support, were identified. Suicide intervention programmes and depression counselling should target older students and students of lower socioeconomic status. Students presenting to university clinics with non-inflammatory joint pain, headache, and/or sleep disorders should be evaluated for suicidal tendencies. The TDQ and CHQ are potentially valuable screening tests for early detection of potential suicidal students.</p>

Two strategies to intensify evidence-based medicine education of undergraduate students: a randomised controlled trial

<p><b>INTRODUCTION</b>Undergraduate evidence-based practice (EBP) is usually taught through standalone courses and workshops away from clinical practice. This study compared the effects of 2 clinically integrated educational strategies on final year medical students.</p><p><b>MATERIALS AND METHODS</b>Final year medical students rotating to the general medicine service for a 2-week internship were randomly assigned to participate in a weekly EBP-structured case conference focusing on students' primary care patients (Group A, n = 47), or to receive a weekly didactic lecture about EBP (Group B, n = 47). The teaching effects of these 2 interventions were evaluated by a validated instrument for assessment of EBP related knowledge (EBP-K), attitude (EBP-A), personal application (EBP-P), and anticipated future use (EBP-F) on the first and last days of rotation.</p><p><b>RESULTS</b>All scores improved significantly after the 2-week EBM-teaching for both groups. When compared to Group B, students in Group A had significantly higher post-intervention scores of EBP-K (21.2 ± 3.5 vs 19.0 ± 4.6; ie. 57.8 ± 72.9% vs 29.1 ± 39.1%; P <0.01) and EBP-P (18.7 ± 4.3 vs 15.3 ± 3.9; ie. 28.5 ± 25.5 % vs 14.1 ± 18.7 %; P <0.001). In contrast, the scores of EBP-A and EBP-F were similar between the 2 groups.</p><p><b>CONCLUSION</b>Structured case conference, when compared to the didactic lectures, significantly improved EBP-K and EBP-P for final year medical students.</p>