A federal advisory panel’s recommendations on screening for diabetes might miss up to 55% of individuals with diabetes or prediabetes, new research indicates, with racial and ethnic minority patients particularly likely to be overlooked (PLoS Med 2016; 13: e1002074).
In 2015, the U.S. Preventive Services Task Force (USPSTF) recommended screening for diabetes in all patients ages 40 to 76 and those who are overweight or obese. Researchers at Northwestern University in Chicago wanted to assess how well these criteria would capture individuals with dysglycemia—prediabetes and diabetes.
The investigators conducted a retrospective analysis of electronic health record (EHR) data from 50,515 primary care patients from six health centers, who had a first office visit between 2008 and 2010 and were followed for up to 3 years. The investigators extracted EHR data on various demographic variables as well as lab testing results, medications, and comorbidities.
Their primary outcome of interest was development of dysglycemia, which they delineated in three ways. First, lab test results consistent with dysglycemia, defined as fasting glucose ≥100 mg/dL, 2-hour postload glucose ≥140 mg/dL, random glucose ≥200 mg/dL, or HbA1c ≥5.7%. The other two criteria for dysglycemia included diagnostic codes for prediabetes or type 2 diabetes, and an antidiabetic medication order.
Just one-quarter of patients (12,679) would have been eligible for screening according to the USPSTF recommendations, which would have yielded a sensitivity and specificity of 45% and 71.9%, respectively.
Overall, nearly 30,000 patients (59.3%) actually received testing for glycemia during the 3-year follow-up, and of these, 8,478 developed dysglycemia. Less than half of these dysglycemic individuals (45%) would have been identified for screening according to the USPSTF recommendations.
Among patients found to have dysglycemia, the USPSTF screening criteria would have recommended screening in just 54.5% of whites, 50.3% of blacks, and 37.7% of Hispanics. This finding illuminates that more black and Hispanic patients develop dysglycemia than whites even when they have a normal weight or are younger than age 40, according to the researchers.
Of patients identified with dysglycemia via lab test results, most had HbA1c testing (77.9%), followed by fasting glucose (18.2%), 2-hour postload glucose (0.7%), and random glucose (3.1%).
The authors pointed out that while providers might consider screening patients—especially minorities—who do not meet USPSTF criteria, doing so could have financial consequences for patients. “Under a provision in the Affordable Care Act, all services recommended by the USPSTF must be fully covered by insurers. Therefore, a patient who falls outside the diabetes screening guidelines and requests a test may have to pay out of pocket,” they wrote in an associated news release.
Elevated Troponin I in Heart Donors OK for Transplantation
The largest study of its kind indicates that elevated troponin (cTn) I levels in heart transplant donors who had preserved left ventricular ejection fraction (LVEF) are not associated with short- or intermediate-term survival in transplant recipients, or rates of primary graft failure or cardiac allograph vasculopathy (Circ Heart Fail 2016; 9:e002909). The findings could liberalize heart transplant acceptance criteria, increasing the number of available donor hearts.
Prior studies exploring recipient outcomes after heart transplantation from donors who had elevated cTn I levels have had mixed results. While there is no formal guidance to reject hearts from donors who had elevated cTn I levels, most transplant centers do.
The number of heart transplants in the U.S. has remained stable over the past 2 decades at about 2,000–2,400 per year, mostly due to limited donor organ availability. Only about one-third of offered donor hearts are accepted, according to the researchers. This led them to conduct a study that included more patients for more statistical power in considering the association between donor cTn I levels and recipient outcomes.
The authors identified through the United Network of Organ Sharing database 10,943 heart transplant cases in which the donor had preserved LVEF ≥50% and for whom cTn I levels were available. They divided this cohort into three groups based on the donors’ peak cTn I levels, <1 ng/mL; 1–10 ng/mL; and >10 ng/mL. The investigators assessed 30-day and 1-, 3-, and 5-year mortality, and found no significant difference among the three groups. Primary graft failure up to 30 days post-transplant and cardiac allograph vasculopathy up to 5 years after transplant also did not differ among the three groups.
Toll of Synthetic Cannabinoid Use Detailed
Synthetic cannabinoid use in the U.S. is rising markedly, and a new report from the Toxicology Investigators Consortium (ToxIC) details the toll of drugs known by an assortment of names like K2, Spice, Smacked, and AK-47 is having on users. ToxIC researchers reported treating 456 patients for synthetic cannabinoid intoxication between 2010 and 2015 (MMWR Morb Mortal Wkly Rep. 2016 Jul 15;65:692-5). Of these cases, 277 patients reported overdosing solely from synthetic cannibinoids.
While 70% of overdose patients were adults ages 19 to 65, more than one-quarter (27.4%) were ages 13 to 18. Most all the patients (83.1%) were males, and 91% experienced clinical signs or symptoms of acute intoxication. Three patients died, one who reportedly used only synthetic cannabinoids, and two who took multiple drugs.
The authors emphasized that synthetic cannabinoids are 2 to 100 times more potent than ∆9-tetrahydrocannabinoil, the principal psychoactive component of cannabis.
ToxIC researchers stressed that their findings were not representative of the entire U.S. or even the cities of participating ToxIC sites.