OBJECTIVE -Angiotensin II has been shown to increase hepatic glucose production and decrease insulin sensitivity. Patients who utilize either an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB) may experience a decreased incidence of new-onset type 2 diabetes. RESEARCH DESIGN AND METHODS-Three reviewers conducted a systematic literature search of Medline, EMBASE, CINAHL, and the Cochrane Library (1966 to present) to extract a consensus of trial data involving an ACEI or ARB with an end point of new-onset type 2 diabetes. Studies were included if they were randomized controlled trials verses placebo/ routine therapy. A random-effects model was utilized. Subgroup and sensitivity analyses were conducted. . No statistical heterogeneity was observed for any evaluation (P Ͼ 0.1 for all comparisons). ACEIs and ARBs did not reduce the odds of mortality, cardiovascular, or cerebrovascular events versus control therapy among all of these studies combined or the hypertension trials. ACEIs and ARBs did reduce the odds of these outcomes among the coronary artery disease studies versus control therapy. RESULTSCONCLUSIONS -ACEIs or ARBs may decrease patients' odds of developing new-onset type 2 diabetes but does not reduce the odds of mortality, cardiovascular, or cerebrovascular outcomes over the study follow-up periods among patients with hypertension. Diabetes Care 28:2261-2266, 2005G iven the elevated risk of morbidity and mortality among patients with type 2 diabetes, prevention of type 2 diabetes is a worthwhile goal. Substantive weight loss eliminates insulinresistant fatty tissue and reduces the risk of progressing from impaired glucose tolerance to full-blown type 2 diabetes by 37-58% (1). Metformin and thiazolidinedione therapy also reduces the rate of type 2 diabetes onset among patients with impaired glucose tolerance or gestational diabetes history by 31-55% (1).ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have been used for years to reduce the rate of diabetic nephropathy progression in patients with type 2 diabetes (2). In addition, ACEIs and ARBs enhance insulin sensitivity and therefore benefit patients at high risk of developing type 2 diabetes. ACEIs improved the insulin sensitivity index by 12.1 Ϯ 15.8% in a compilation of 20 pharmacologic trials, while ARBs raised the insulin sensitivity index by 18.7 Ϯ 17.9% in a compilation of 9 pharmacologic trials (1).ACEIs and ARBs have been studied versus placebo or control therapy in numerous clinical trials of patients who had hypertension, coronary artery disease, or chronic heart failure. In secondary subgroup analyses, the impact of ACEI or ARB usage on the development of newonset type 2 diabetes has been evaluated. While many trials showed significant benefits in preventing new-onset type 2 diabetes, several other trials did not (3-17). One way to reconcile these clinical trial differences is through the use of meta-analysis. Meta-analysis allows incorporation of data from several studies into a single analysis with increased power ...
There are positive as well as negative aspects for physicians-in-training to caring for patients with alcohol and illegal drug abuse problems. Combining effective education strategies with the needs of physicians at specific points in their education may be effective in reversing the negative trends seen in attitudes toward caring for patients with substance abuse problems.
Complications secondary to the use of oral contraceptive agents are rare. Hepatobiliary complications, while often dramatic in presentation, occur infrequently. In a patient without predisposing conditions to complications, the benefits achieved with estrogen/progesterone products outweigh the risks. Those conditions that would absolutely and relatively contraindicate the use of oral contraceptives are listed in Table 4. Patients with a past history of liver disease in whom liver function tests have returned to normal may tolerate the introduction of oral contraceptives. They need to be monitored closely for adverse reactions. Patients who have experienced cholestatic jaundice of pregnancy should avoid all contraceptives because of a high risk of disease recurrence. Women whose first-degree relatives have experienced cholestasis of pregnancy or oral contraceptive-induced cholestasis may be at increased risk and should be closely monitored while taking birth-control pills. Women with current or previous benign or malignant hepatic tumors should not take oral contraceptives. Active hepatitis is an absolute contraindication to using birth control pills, although patients with a past history of hepatitis and no evidence of active disease can have a trial of these drugs with close follow-up. A final group of women who should avoid oral contraceptives is those with familial defects of biliary excretion, including the Dubin-Johnson syndrome, Rotor's syndrome, and benign intrahepatic recurrent cholestasis. Dubin-Johnson syndrome is often asymptomatic and may manifest only during pregnancy or during the use of oral contraceptives. The reduction in hepatic excretory function induced by the sex steroids can transform the mild hyperbilirubinemia into frank jaundice. Oral contraceptive agents are the most widely used reversible means of birth control currently available. Fortunately, the complications associated with these drugs are infrequent and may be decreasing due to lower-dose products. Complications still occur, however, and need to be recognized by the general internist as medication-induced problems so the offending drugs can be discontinued and appropriate treatment and follow-up initiated. In addition, patients at risk for the development of complications need to be recognized and advised prior to the introduction of oral contraceptives.
An intensive integrated acute medicine rotation in geriatrics improved residents' knowledge of geriatric medicine. The presence of a geriatrics-trained attending physician was not necessary for this improvement. Residents' attitudes toward geriatric medicine and their geriatrics education were generally positive and were not influenced by this experience.
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