New Methods for Measuring Glucose Control: Translation of the Hemoglobin A1c Assay
November is American Diabetes Month, a time to communicate the seriousness of diabetes and the importance of proper diabetes control. Visit the American Diabetes Association Web site athttp://www.diabetes.org/communityprograms-and-localevents/americandiabetesmonth.for downloadable diabetes fact sheets and other tools for promoting diabetes awareness this month.
One of the major clinical tools in the management of diabetes is the hemoglobin A1c (A1C) assay. The measurement of A1C is based on the structural and biochemical properties of adult hemoglobin (hemoglobin A), which comprises approximately 97% of total hemoglobin. Most glycation occurs in the A1C component. As the blood glucose level increases, so does the amount of glycation (the nonenzymatic binding of a sugar [eg, glucose] to another molecule [eg, protein]). Since the lifespan of the red blood cell is approximately 120 days, the A1C reflects the ambient blood glucose concentration over the previous 2 to 3 months. Therefore, the A1C is considered reflective of long-term glucose control. Major clinical trials such as the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes have demonstrated that reductions in A1C are associated with a decrease in diabetes-related complications.
A1C assays that are standardized to the DCCT methodology are the most widely used method for assessing chronic glucose control in research and clinical practice; however, they are not used worldwide. Using methods that are standardized to DCCT methodology, the American Diabetes Association (ADA) recommends that general target A1C values are less than 7%. Recently, the International Federation of Clinical Chemists (IFCC) developed a new and more precise reference standard that will give values approximately 1.5% to 2.0% lower than that of DCCT standardized methods. In addition, the IFCC values are expressed in international units (mmol/mol). Potentially, this reporting could result in confusion among patients and providers, along with deterioration in glucose control. Recognizing this potential problem, the ADA, European Association for the Study of Diabetes, International Diabetes Federation, and IFCC developed a consensus statement suggesting that the A1C test results should be standardized worldwide and reported as IFCC units (mmol/mol), DCCT-aligned values (percent), and A1C-derived average glucose value (mg/dL or mmol/L).
The consensus statement recognized that the ability to calculate A1C-derived average glucose values depended on the ability to develop mathematical equations that can predict average glucose levels from A1C levels. A linear regression equation has been derived to predict average glucose for A1C values. Potentially, clinicians will be able to calculate average glucose just as one calculates estimated glomerular filtration rate.
References
1. Consensus Statement of the Worldwide Standardization of the Hemoglobin A1c Measurement: The American Diabetes Association, European Association for the Study of Diabetes, International Federation of Clinical Chemistry and Laboratory Medicine, and the International Diabetes Federation. Diabetes Care. 2007;30:2399-2400.
2. Translating the A1C Assay. Diabetes Care. 2008;31(8):1704-1707.
3. Translating the A1C assay into estimated average glucose values. Diabetes Care.2008;31(8):1473-1478.
PCNA Chapters-Bringing Cardiovascular Prevention and Management to You!
PCNA is happy to be able to offer local activities and education to members through our nearly 20 chapters located around the United States and Montreal, Canada. This year, PCNA chapters have been busier than ever, offering meetings on topics from valvuloplasty to erectile dysfunction, and hosting community education, screening fairs, and cardiac/vascular nurse certification review courses.
It is never too late to become involved in your local chapter! Visit http://www.pcna.net/chapters for local chapter meeting information. Below is a review of what just a few PCNA chapters planned in 2008.
New Chapters
In August 2008, the First Coast and the Greater Cincinnati Area Chapters joined our ever-expanding "family" of regional chapters! The First Coast Chapter is led by Irma Ancheta and serves the Jacksonville, Florida, area. Barbara Bell is the president of the Greater Cincinnati Area Chapter, which serves the tristate region of Southwest Ohio, Southeast Indiana, and Northwest Kentucky.
Ms Ancheta, supported by Lori Weaver, held a kickoff meeting on July 15. The event was held at the University of North Florida, and more than 50 healthcare providers attended. Central Florida PCNA Chapter Leader Sandra Kreul, ARNP-C, presented a clinical discussion on lipid homeostatis.
Ms Bell and her co-leaders, Monica Worrell and Cathy Jenkins, held a well-attended meeting on September 18 on the topic of elevated triglycerides and low high-density lipoprotein.
Chicagoland
New Chicagoland leader Dawn Koch and outgoing Chapter President and new PCNA Board Member Lola Coke have been busy planning a fall "how to" session on developing a community education and screening fair.
At this session, 3 speakers from different cultures including African American, Hispanic, and Indian presented healthcare-related facts to attendees. Using the information presented, those interested in holding a community education and screening fair are better prepared to serve education and screening fair participants. In addition, the how to session attendees were able to select from a variety of materials from PCNA to use in planning and presenting information and for distribution to education and screening fair attendees.
Montreal, Quebec
Montreal Chapter Leaders Dominique Robert and Wendy Wray are very pleased with the high-quality programs that their chapter has been able to bring to members this year. Over the past 12 months, the Montreal Chapter has hosted 4 meetings on a number of topics. In February, Dr Martucci, interventional cardiologist specializing in adult congenital cardiomyopathy at the McGill University Health Center, presented a talk on valvuloplasty. In addition to Dr Martucci's talk, Rosetta Antonacci, head nurse of the Clinical Teaching Unit at St Mary's Hospital in Montreal, presented a cardiac follow-up program. Ms Antonacci was able to expand on this talk by presenting a poster on the same topic at the 2008 PCNA Symposium in Orlando, Florida.
Dr Vidal Essebag, director of Cardiac Electrophysiology at McGill University Health Center, presented electrophysiological treatment and prevention of arrhythmias to a large crowd of healthcare providers in May 2008.
Throughout the year, leaders have collaborated on the development of a Cardiac Discharge Teaching Package for critical care unit patients, which was delivered in September 2008.
Central Virginia
Central Virginia Chapter (CVC) President Suzanne Fuhrmeister and fellow leaders have hosted several meetings in 2008.
One of this chapter's objectives is to offer professional development to members. In February 2008, the CVC held an "enthusiastically received program" on erectile dysfunction, presented by Hemant Solomon, MD. The CVC was host to a half-day program in February on acute coronary syndrome/myocardial infarction, point-of-care testing, and residual risk.
In addition to educational programs, the CVC supports members in the area by offering professional development opportunities. In August 2007, the CVC sponsored a cardiac/vascular certification review course. This program was wildly popular, so much so that leaders had to cap attendance and are considering sponsoring this program every 2 years.
A second objective of the chapter is to support community initiatives that promote fitness, risk identification, disease prevention, and education. In October 2008, chapter members coordinated a team to participate in a Remote Area Medical (RAM) clinic that serves Southwestern Virginia, a rural area with a high proportion of citizens without insurance and lacking in numbers and type of healthcare services. RAM is a not-for-profit organization periodically offering weekend clinics in the Appalachian areas. Heart disease and related problems were the number 1 problem of people attending the clinic.
Holiday Stress and Nutrition or How to Put Mind Over Mouth
Here are tips for patients (and ourselves) to help get through stressful times without mindlessly eating.
* Acknowledge that you are stressed. We do not always recognize stress. Learn to recognize your stress signals, which might include headaches, rapid breathing, shoulder strain, or snacking when you are not hungry.
* Enjoy what you are eating. We get comfort from food by its tastes, textures, and smells. If we stuff food in our mouth without noticing its qualities, we are not gaining its comfort. The more we savor our food, the fewer bites we will need to get the comfort we seek.
* Do not eat and do something else. If you are eating, eat. Try not to eat at the computer, TV, or car. If you only eat, it is easier to appreciate and listen to gradual fullness.
* Pause. If you find yourself mindlessly diving into a bag of potato chips, stop and check in with yourself. Think: do I really want to eat this? Is it going to be helpful? Taking this moment to reflect can help interrupt the automatic urge to snack.
* Do not ignore your cravings. Let yourself have the item you crave, but have only 1 and truly enjoy it. Enjoy its taste, texture, and smell. Denying yourself the item entirely may strengthen your desire to have many.
* Eat only until you are three-quarters full. If zero is famished and 10 is "Thanksgiving full," strive for 7 or 8 at the end of a meal. This feels a little like being "hungry" when you are just getting used to it. After a few days, however, "Thanksgiving full" will feel uncomfortable and you will naturally eat smaller portions.
Please visit http://www.pcna.net/library/holidaystress.pdf for a copy of these tips as well as links to additional resources for your patients.
Cardiovascular Nurses Association Awarded Resourcefully Enhancing Aging in Specialty Nursing Grant
Collaborative Initiative to Develop and Enhance Specialty Nursing Resources for Nurses on Care of Older Patients
Preventive Cardiovascular Nurses Association has been awarded a grant by the Hartford Institute for Geriatric Nursing at the New York University College of Nursing as part of an initiative called Resourcefully Enhancing Aging in Specialty Nursing (REASN). Resourcefully Enhancing Aging in Specialty Nursing is a 4-year initiative that works with specialty nursing associations to deepen their involvement in enhancing their members' competency in caring for older adults and aims to bring up-to-date information on geriatric best practices to more than 200,000 hospital-based specialty nurses. The REASN initiative is funded with a $2.3 million dollar grant from The AtlanticPhilanthropies (USA) Inc.
Resourcefully Enhancing Aging in Specialty Nursing builds on past Hartford Institute work to engage specialty nursing organizations in an effort to raise awareness that most people being cared for by nurses in various specialties are older than 65 years. It focuses on building intensive collaborations with select specialty nursing associations that will, in turn, influence the care provided to older adults in the hospital setting. Preventive Cardiovascular Nurses Association will receive a 2-year grant of $15,000 to develop clinical print and Web-based materials geared toward geriatric care in the prevention and management of cardiovascular disease and to create sustainable infrastructures for geriatric initiatives within the organization. Preventive Cardiovascular Nurses Association will also receive up to $2,000 to sustain and/or develop its Web fellow program, which aims at ensuring that content related to care of older adults is easily accessible and visible on specialty nursing association Web sites.
The REASN initiative will support the Hartford Institute's geriatric clinical content Web site, http://ConsultGeriRN.org.ConsultGeriRN.org continues be the resource for nurses on evidence-based clinical protocols and topics on the care of older adults. For more information REASN, specialty practice resources, and geriatric nursing clinical content, please visit http://www.ConsultGeriRN.org.
The Hartford Institute for Geriatric Nursing at New York University's College of Nursing is the only nurse-led organization in the country that seeks to shape the quality of healthcare that older Americans receive by promoting the highest level of geriatric competence in all nurses. By raising the standards of nursing care, the Hartford Institute aims to ensure that people age with optimal function, comfort, and dignity. The Hartford Institute is recognized as unique in its focus on disseminating best practices to nursing students, faculty, practicing nurses, and policy makers(http://www.HartfordIGN.org, http://www.ConsultGeriRN.org, http://www.NICHEProgram.org).
Medicare Improvement Bill is Voted Into Law
On Thursday, July 9, the senate approved the Medicare Improvement for Patients and Providers Act of 2008, HR 6331. The key provisions of this very extensive bill include eliminating the pending 10% cut in Medicare payments for physicians, providing incentives for quality care (pay for performance), enhancing access to preventive and mental health services, and improving low-income assistance programs to Medicare beneficiaries. The entire document with all of its provisions, may be viewed/downloaded at http://www.govtrack.us/data/us/bills.text/110/h/h6331.pdf.
Preventive Cardiovascular Nurses Association members will take special interest in section 144, which establishes both cardiac and pulmonary rehabilitation services as specific Medicare benefit categories that mandate coverage and payment of services. This provision extends cardiac rehabilitation benefits to patients who have undergone valve repair or replacement, had percutaneous transluminal coronary angioplasty or coronary stenting, or had a heart transplant. Patients having had a myocardial infarction or coronary artery bypass graft and those with stable angina continue to be covered, as in the past. Extensive coverage (72 one-hour visits) is allowed for intensive cardiac rehabilitation programs that positively affect the progression of coronary heart disease or reduce the need for coronary interventions and has demonstrated significant reductions in 5 or more of the following measures: (1) lowdensity lipoprotein cholesterol; (2) triglyceride; (3) body mass index; (4) systolic blood pressure; (5) diastolic blood pressure; and (6) the need for cholesterol, blood pressure, and diabetes medications. This document not only recognizes but also encourages services beyond "physician-prescribed exercise" in its description of cardiac rehabilitation. It states that these services should include cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes measurement. The effective date for these changes to take place is January 1, 2010. Preventive Cardiovascular Nurses Association congratulates American Association of Cardiovascular and Pulmonary Rehabilitation for their persistent efforts in ensuring that these important provisions, now termed the Pulmonary and Cardiac Rehabilitation Act of 2008, become a law.
Section Description
The Journal of Cardiovascular Nursing is the official journal of the Preventive Cardiovascular Nurses Association. PCNA is the leading nursing organization dedicated to preventing cardiovascular disease through assessing risk, facilitating lifestyle changes, and guiding individuals to achieve treatment goals.