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OBJECTIVE:-- To examine whether hyperglycemia at the time of presentation was associated with outcomes in patients admitted to non-intensive care settings with community-acquired pneumonia (CAP). RESEARCH DESIGN AND METHODS-- Prospective cohort study of consecutive patients admitted to six hospitals between 15 November 2000 and 14 November 2002. RESULTS:-- Of the 2,471 patients in this study (median age 75 years), 279 (11%) had serum glucose at presentation >11 mmol/l: 178 of the 401 patients (44%) with a prior diagnosis of diabetes and 101 of the 2,070 patients (5%) without a history of diabetes. Of patients hospitalized with CAP, 9% died and 23% suffered an in-hospital complication. Compared with those with values 11 mmol/l had an increased risk of death (13 vs. 9%, P = 0.03) and in-hospital complications (29 vs. 22%, P = 0.01). Compared with those patients with admission glucose 11 mmol/l. Even after adjustment for factors in the Pneumonia Severity Index, hyperglycemia on admission remained significantly associated with subsequent adverse outcomes: for each 1-mmol/l increase, risk of in-hospital complications increased 3% (0.2-6%). CONCLUSIONS:-- Hyperglycemia on admission is independently associated with adverse outcomes in patients with CAP, with the increased risks evident at lower glucose levels than previously reported.

Elderly people (aged 65 years or more) are at increased risk of polypharmacy (five or more medications), inappropriate medication use, and associated increased health care costs. The use of clinical decision support (CDS) within an electronic medical record (EMR) could improve medication safety. Participatory action research methods were applied to preproduction design and development and postproduction optimization of an EMR-embedded CDS implementation of the Beers' Criteria for medication management and the Cockcroft-Gault formula for estimating glomerular filtration rates (GFR). The \"Seniors Medication Alert and Review Technologies\" (SMART) intervention was used in primary care and geriatrics specialty clinics. Passive (chart messages) and active (order-entry alerts) prompts exposed potentially inappropriate medications, decreased GFR, and the possible need for medication adjustments. Physician reactions were assessed using surveys, EMR simulations, focus groups, and semi-structured interviews. EMR audit data were used to identify eligible patient encounters, the frequency of CDS events, how alerts were managed, and when evidence links were followed. Analysis of subjective data revealed that most clinicians agreed that CDS appeared at appropriate times during patient care. Although managing alerts incurred a modest time burden, most also agreed that workflow was not disrupted. Prevalent concerns related to clinician accountability and potential liability. Approximately 36% of eligible encounters triggered at least one SMART alert, with GFR alert, and most frequent medication warnings were with hypnotics and anticholinergics. Approximately 25% of alerts were overridden and ~15% elicited an evidence check. While most SMART alerts validated clinician choices, they were received as valuable reminders for evidence-informed care and education. Data from this study may aid other attempts to implement Beers' Criteria in ambulatory care EMRs.

Vascular Compliance Is Reduced in the Early Stages of Type 1 Diabetes Jacques S. Romney , MD and Richard Z. Lewanczuk , MD, PHD Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada Abstract OBJECTIVE —To determine whether arterial compliance of patients with type 1 diabetes is reduced before the development of clinically apparent diabetes complications. RESEARCH DESIGN AND METHODS —Pulse-wave analysis was used to compare vascular compliance between patients with type 1 diabetes and nondiabetic control subjects. Analysis of covariance was used to determine differences between the two groups with adjustment for age if needed. RESULTS —A total of 59 patients with type 1 diabetes were studied; age ranged from 17–61 years. Of the 59 patients, 32 had no evidence of diabetes complications and 27 had microvascular complications. The control group consisted of 57 healthy subjects ranging in age from 23–79 years. In the control group, large artery compliance (C1) and small artery compliance (C2) were inversely proportional to age ( r = −0.55 for C1 and −0.50 for C2; P < 0.01). When the control subjects were compared with type 1 diabetic patients without microvascular complications, C1 was 1.51 ± 0.04 (SEM) for the control group and 1.33 ± 0.06 (SE) ml/mmHg for the diabetic group, whereas C2 was 0.080 ± 0.005 (SE) and 0.065 ± 0.005 (SE) ml/mmHg for the control and diabetic subjects, respectively, when adjusted for age ( P = 0.03 for both C1 and C2). CONCLUSIONS —Vascular compliance of both the large and small arteries is reduced in type 1 diabetic patients before any clinical complications from the diabetes are evident. This study serves to emphasize that vascular changes occur at an early point in the disease and may increase risk of cardiovascular events in patients with diabetes. Larger prospective studies are required to confirm this finding and to investigate the efficacy of medical intervention. ANCOVA, analysis of covariance C1, large artery compliance C2, small artery compliance Footnotes Address correspondence and reprint requests to Richard Z. Lewanczuk MD, PhD, Room 362, Heritage Medical Research Building, University of Alberta, Edmonton, Alberta T6G 2S2, Canada. E-mail: rlewancz{at}ualberta.ca . Received for publication 16 March 2001 and accepted in revised form 20 August 2001. A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

Arterial vascular compliance is known to decrease with age, hypertension, atherosclerosis and in the presence of type 2 diabetes. This study aimed to examine large artery (C1) and small artery (C2) compliance in patients with type 1 diabetes mellitus before any complications from diabetes had developed clinically. The vascular compliance of 32 patients with type 1 diabetes and 57 healthy controls was measured using an HDI/Pulsewave Cardiovascular Profiling Instrument CR-2000. Analysis of variance and covariance was performed for C1 and C2 was calculated using pulse wave contour analysis and the modified Windkessel model. Covariables included age, gender smoking, the use of antihypertensive medications and systemic vascular resistance. C1 and C2 were found to be inversely proportional to age in the control group (C1 r=-.55, C2 r=-.50). In addition, males had greater C1 and C2 than females. There was no statistical difference between the diabetic and control groups for gender, BMI, diastolic BP or systemic vascular resistance. Statistical differences (p<.05) were present for systolic BP (126 ± 10 vs 123 ± 14 mmHg), age-adjusted C1 (1.47 ± .33 vs 1.71 ± .39 ml/mmHg) and age-adjusted C2 (0.075 ± .21 vs 0.93 ± .33 ml/mmHg) for diabetics and controls respectively. Thus, the vascular compliance of the diabetic groups was significantly diminished when adjusted for age despite normal blood pressure and systemic vascular resistance. In conclusion, C1 and C2 in healthy, normotensive type 1 diabetics without clinical complications were considerably lower than expected for age. This study furthers the evidence that patients with type 1 diabetes are at greater cardiovascular risk from an earlier age.

Given the ever increasing epidemic of diabetes and obesity, I'm surprised and saddened that The Journal...