Systolic Blood Pressure Control Among Individuals With Type 2 Diabetes: A Comparative Effectiveness Analysis of Three Interventions.

BACKGROUND: The relative effectiveness of 3 approaches to blood pressure control-(i) an intensive lifestyle intervention (ILI) focused on weight loss, (ii) frequent goal-based monitoring of blood pressure with pharmacological management, and (iii) education and support-has not been established among overweight and obese adults with type 2 diabetes who are appropriate for each intervention. METHODS: Participants from the Action for Health in Diabetes (Look AHEAD) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) cohorts who met criteria for both clinical trials were identified. The proportions of these individuals with systolic blood pressure (SBP) <140 mm Hg from annual standardized assessments over time were compared with generalized estimating equations. RESULTS: Across 4 years among 480 Look AHEAD and 1,129 ACCORD participants with baseline SBPs between 130 and 159 mm Hg, ILI (OR = 1.46; 95% CI = [1.18-1.81]) and frequent goal-based monitoring with pharmacotherapy (OR = 1.51; 95% CI = [1.16-1.97]) yielded higher rates of blood pressure control compared to education and support. The intensive behavioral-based intervention may have been more effective among individuals with body mass index >30 kg/m2, while frequent goal-based monitoring with medication management may be more effective among individuals with lower body mass index (interaction P = 0.047). CONCLUSIONS: Among overweight and obese adults with type 2 diabetes, both ILI and frequent goal-based monitoring with pharmacological management can be successful strategies for blood pressure control. CLINICAL TRIALS REGISTRY: clinicaltrials.gov identifiers NCT00017953 (Look AHEAD) and NCT00000620 (ACCORD).

Longitudinal analysis of one million vital signs in patients in an academic medical center.

BACKGROUND: Recognition of critically abnormal vital signs has been used to identify critically ill patients for activation of rapid response teams. Most studies have only analyzed vital signs obtained at the time of admission. The intent of this study was to examine the association of critical vital signs occurring at any time during the hospitalization with mortality. METHODS: All vital sign measurements were obtained for hospitalizations from January 1, 2008 to June 30, 2009 at a large academic medical center. RESULTS: There were 1.15 million individual vital sign determinations obtained in 42,430 admissions on 27,722 patients. Critical vital signs were defined as a systolic blood pressure <85 mmHg, heart rate >120 bpm, temperature <35°C or >38.9°C, oxygen saturation <91%, respiratory rate ≤ 12 or ≥ 24, and level of consciousness recorded as anything but "alert". The presence of a solitary critically abnormal vital sign was associated with a mortality of 0.92% vs. a mortality of 23.6% for three simultaneous critical vital signs. Of those experiencing three simultaneous critical vital signs, only 25% did so within 24h of admission. The Modified Early Warning Score (MEWS) and VitalPAC Early Warning Score (VIEWS) were validated as good predictors of mortality at any time point during the hospitalization. CONCLUSIONS: The simultaneous presence of three critically abnormal vital signs can occur at any time during the hospital admission and is associated with very high mortality. Early recognition of these events presents an opportunity for decreasing mortality.

Sickle cell trait and development of microvascular complications in diabetes mellitus.

BACKGROUND AND OBJECTIVES: Many African Americans (AA) have both sickle cell trait (SCT) and diabetes mellitus. The objective of this study was to determine whether individuals with diabetes mellitus and SCT have higher rates of microvascular complications relative to those without SCT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a retrospective study comparing albuminuria, estimated GFR (eGFR), and microvascular complications in AA with diabetes on the basis of presence of SCT. The study included 821 outpatients who underwent hemoglobin A1c (HbA1c) testing, and presence of SCT was determined using the HbA1c assay. Medical record review and telephone interviews were performed for AA participants. RESULTS: Data were obtained on 376 AA patients (110 with SCT, 245 with neither SCT nor hemoglobin C trait, and 21 with hemoglobin C trait) and 445 European Americans. The mean eGFR and urinary protein excretion were similar between the three AA subgroups. Analysis revealed that 36.3% of AA nontrait and 22.7% of AA SCT participants had retinopathy, peripheral vascular disease, or end-stage kidney disease (P = 0.01). After adjustment for diabetes duration, age, insulin use, and gender, differences in the prevalence of microvascular complications were not observed. CONCLUSIONS: SCT does not increase the risk of microvascular complications in AA with diabetes mellitus.