choosing wisely

1. Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease (<10% in 10 years).

2. Don’t obtain imaging studies in patients with non-specific low back pain.

3. In patients with witnessed syncope but with no suggestion of seizure and no report of other neurologic symptoms or signs, the likelihood of a central nervous system (CNS) cause of the event is extremely low and patient outcomes are not improved with brain imaging studies

4. In patients with low pretest probability of VTE as defined by the Wells prediction rules, a negative high-sensitivity D-dimer measurement effectively excludes VTE and the need for further imaging studies.

5. Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. In the absence of cardiopulmonary symptoms, preoperative chest radiography rarely provides any meaningful changes or improve patient outcomes.

Insulin Therapy for Type 2 Diabetes Mellitus

Insulin Therapy for Type 2 Diabetes Mellitus

The hemoglobin A1c target for most patients with type 2 diabetes is 7% 

 Ismail-Beigi et al: targed approximately 8%:  Increased risk of hypoglycemia, reduced life expectancy,

extensive comorbidities (renal/liver failure- alcohol abuse), cardiovascular diseases, DM duration or reduced resources. 

Insulin adverse effects include weight gain and hypoglycemia.

Basal insulin can be added to oral hypoglycemic agents (generally stopping sulfonylureas)

initially, and later, prandial insulin can be added in a stepwise fashion. 

1. Insulin Resistance: impaired ability to suppress hepatic glucose production a peripheral glucose uptake.

2. Progressive imparirment of insulin secretion.

ACCORD HBA1c less than 6,0% more harmfull. 7,0-7.9 % less hypoglicemia and mortality. 

DCCT/EDIC  Increase in HBA1c from 7% to 8%. Results in an absolute increase from 1 event per year to only 2 events per year of retinopathy progression. 

Lower HbA1c goals: younger, not developed hypoglycemia, and when the benefits of microvascular

disease protection outweigh the risks of hypoglycemia.