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Hollander PA, Krause-Steinrauf H, Butera NM, Kazemi EJ, Ahmann AJ, Fattaleh BN, Johnson ML, Killean T, Lagari VS, Larkin ME, Legowski EA, Rasouli N, Willis HJ, Martin CL. The Use of Rescue Insulin in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). Diabetes Care 2024; 47:638-645. [PMID: 37756542 PMCID: PMC10973913 DOI: 10.2337/dc23-0516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/18/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE To describe rescue insulin use and associated factors in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE). RESEARCH DESIGN AND METHODS GRADE participants (type 2 diabetes duration <10 years, baseline A1C 6.8%-8.5% on metformin monotherapy, N = 5,047) were randomly assigned to insulin glargine U-100, glimepiride, liraglutide, or sitagliptin and followed quarterly for a mean of 5 years. Rescue insulin (glargine or aspart) was to be started within 6 weeks of A1C >7.5%, confirmed. Reasons for delaying rescue insulin were reported by staff-completed survey. RESULTS Nearly one-half of GRADE participants (N = 2,387 [47.3%]) met the threshold for rescue insulin. Among participants assigned to glimepiride, liraglutide, or sitagliptin, rescue glargine was added by 69% (39% within 6 weeks). Rescue aspart was added by 44% of glargine-assigned participants (19% within 6 weeks) and by 30% of non-glargine-assigned participants (14% within 6 weeks). Higher A1C values were associated with adding rescue insulin. Intention to change health behaviors (diet/lifestyle, adherence to current treatment) and not wanting to take insulin were among the most common reasons reported for not adding rescue insulin within 6 weeks. CONCLUSIONS Proportionately, rescue glargine, when required, was more often used than rescue aspart, and higher A1C values were associated with greater rescue insulin use. Wanting to use noninsulin strategies to improve glycemia was commonly reported, although multiple factors likely contributed to not using rescue insulin. These findings highlight the persistent challenge of intensifying type 2 diabetes treatment with insulin, even in a clinical trial.
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Affiliation(s)
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Nicole M. Butera
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Erin J. Kazemi
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | | | | | - Mary L. Johnson
- International Diabetes Center at Park Nicollet, Minneapolis, MN
| | - Tina Killean
- Southwestern American Indian Center, Phoenix, AZ
| | | | | | - Elizabeth A. Legowski
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Neda Rasouli
- University of Colorado, School of Medicine, and VA Eastern Colorado Health Care System, Aurora, CO
| | - Holly J. Willis
- International Diabetes Center at Park Nicollet, Minneapolis, MN
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Lagari VS, Al-Yatama F, Rodriguez G, Berger HR, Levis S. Under-Recognition of Fractures as Osteoporosis Indicators. Geriatrics (Basel) 2019; 4:geriatrics4010009. [PMID: 31023977 PMCID: PMC6473876 DOI: 10.3390/geriatrics4010009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/31/2018] [Accepted: 01/08/2019] [Indexed: 12/30/2022] Open
Abstract
After the first fracture, the risk of subsequent fractures increases significantly. Medical treatment can reduce the risk of a second fracture by about 50%, but many older adults do not receive osteoporosis medication following their first fracture. This observational study aimed to understand primary care management patterns of older adults after osteoporotic fractures at the Miami Veterans Affairs (VA) Healthcare System. A retrospective review of 219 fracture cases selected by International Classification of Disease (ICD-9) codes between October 2015 and September 2016 identified 114 individuals age ≥50 years who had a non-traumatic fracture code entered in their medical record for the first time. Among them, 72 (63%) did not undergo a bone mineral density (BMD) test or receive treatment in the 12 months following their fracture. Of the 40 individuals who had a BMD test post-fracture, 17 (100%) received or were considered for anti-osteoporosis treatment if their T-score indicated osteoporosis (T-score ≤−2.5), but only 8/23 (35%) if the T-score was >−2.5. Physicians are more likely to prescribe osteoporosis therapy based on a BMD T-score diagnosis of osteoporosis, rather than a clinical diagnosis of osteoporosis based on a low-trauma fracture. A change in practice patterns is necessary to decrease the incidence of fractures.
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Affiliation(s)
- Violet S Lagari
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, 1400 NW 10th Ave Suite 807 Miami, FL 33136, USA.
- Endocrinology Section, Miami Veterans Affairs Healthcare System, 1201 NW 16th St (11GRC), Miami, FL 33125, USA.
| | - Fatima Al-Yatama
- Department of Medicine, Farwaniya Hospital, P.O. Box 13373, Farwaniya 81004, Kuwait.
| | - Gracielena Rodriguez
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, 1400 NW 10th Ave Suite 807 Miami, FL 33136, USA.
- Endocrinology Section, Miami Veterans Affairs Healthcare System, 1201 NW 16th St (11GRC), Miami, FL 33125, USA.
| | - Hara R Berger
- Reproductive Health Physicians, 4675 Ponce de Leon Blvd. Suite 204, Miami, FL 33146, USA.
| | - Silvina Levis
- Department of Medicine, University of Miami School of Medicine, 1600 NW 10th Ave. Suite 1140 Miami, FL 33136, USA.
- Geriatric Research Education and Clinical Center, Miami Veterans Affairs Healthcare System, 1201 NW 16th St (11GRC), Miami, FL 33125, USA.
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Lagari VS, Levis S. Implementation of a feasible monthly vitamin D intervention in homebound older adults using a Meals-on-Wheels programme. Evid Based Nurs 2016; 19:96. [PMID: 27056839 DOI: 10.1136/eb-2016-102331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Violet S Lagari
- University of Miami School of Medicine, Miami, Florida, USA; Miami Veterans Affairs Healthcare System, Miami, Florida, USA
| | - Silvina Levis
- University of Miami School of Medicine, Miami, Florida, USA; Miami Veterans Affairs Healthcare System, Miami, Florida, USA
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Abstract
Osteoporosis remains a challenging disease to treat due to a number of barriers including patient adherence to therapies. One of the most recent advances has been the development of the Fracture Risk Assessment Tool, which is helpful in conveying fracture risk to patients and providing treatment guidance to clinicians. The decision to use an anti-osteoporosis therapy must be tailored to the patient's specific clinical scenario. The bisphosphonates are first-line agents in the treatment of osteoporosis and are efficacious in substantially reducing fracture risk between 25% and 70% on average depending on fracture site. Compliance with oral bisphosphonate pills can be poor, resulting in a significant deterrent to the proper management of osteoporosis. Non-pill forms of bisphosphonate and nonbisphosphonate therapy are available for the treatment of osteoporosis and may increase compliance. Among these is Binosto, a new formulation of weekly effervescent alendronate, as well as intravenous bisphosphonates, teriparatide, and subcutaneously administered denosumab, which are all costly medications and are unlikely to become the mainstay of treatment over the oral bisphosphonate pills. Having a detailed conversation between the patient and physician is essential to the development of a tailored treatment plan that will decrease fracture risk.
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Affiliation(s)
- Violet S Lagari
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami School of Medicine, Miami VA Medical Center , Miami, FL
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Lagari VS, Gómez-Marín O, Levis S. Study design and baseline characteristics of participants in the Vitamin D in Vulnerable Adults at the VA (the VIVA Study). Contemp Clin Trials 2014; 39:66-73. [DOI: 10.1016/j.cct.2014.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 07/25/2014] [Accepted: 07/27/2014] [Indexed: 01/02/2023]
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Abstract
CONTEXT Acute infectious thyroiditis, particularly fungal thyroiditis, is rare and typically presents in immunocompromised individuals. Here we report the first case of coccidiomycosis thyroiditis occurring in an organ recipient as a consequence of likely allograft contamination and discuss the management strategies for thyroid masses in the setting of disseminated infection. EVIDENCE ACQUISITION AND SYNTHESIS In this clinical case seminar, we summarize the previously published cases of coccidiomycosis thyroiditis based on a MEDLINE search of all peer-reviewed publications (original articles and reviews) on this topic. We identified six other cases, five of which also occurred in immunocompromised hosts, although none occurred in organ recipients. CONCLUSION A case of coccidiomycosis thyroiditis occurring in a post-liver transplant immunocompromised host is reported. Analysis of donor serum revealed the liver allograft as the likely infectious source, resulting in hematological spread to the thyroid. Although our patient's thyroid gland was lacking gross structural abnormalities at presentation, new-onset thyroid masses developed after relative immune restoration and initiation of antifungal therapies. The differential diagnosis of new-onset thyroid masses in immunocompromised hosts is discussed, with a focus on immune reconstitution inflammatory syndrome. The role of thyroidectomy in the management of fungal thyroiditis is also discussed.
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Affiliation(s)
- Elizabeth A McAninch
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami, Miami, Florida 33136
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Dang S, Levis S, Lagari VS. If you take it, it works... J Womens Health (Larchmt) 2014; 23:278. [PMID: 24611588 DOI: 10.1089/jwh.2013.4699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stuti Dang
- 1 Department of Medicine, Division of Geriatrics and Gerontology, University of Miami Miller School of Medicine; Geriatric Research , Education, and Clinical Center, Miami VA Medical Center, Miami, Florida
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Abstract
Women have always looked for non-hormonal options to alleviate menopausal vasomotor symptoms and prevent menopausal bone loss. The use of complementary and alternative medicine for these purposes has particularly increased after the publication of the Women's Health Initiative's results suggesting that there might be more risks than benefits with hormone replacement. Phytoestrogens are plant-derived estrogens that, although less potent than estradiol, bind to the estrogen receptor and can function as estrogen agonists or antagonists. Soy isoflavones extracted from soy are the phytoestrogens most commonly used by menopausal women. Because typical Western diets are low in phytoestrogens and taking into account the general difficulty in changing dietary habits, most clinical trials in Western women have used isoflavone-fortified foods or isoflavone tablets. Although some women might experience a reduction in the frequency or severity of hot flashes, most studies point towards the lack of effectiveness of isoflavones derived from soy or red clover, even in large doses, in the prevention of hot flashes and menopausal bone loss. This article is part of a Special Issue entitled 'Phytoestrogens'.
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Affiliation(s)
- Violet S Lagari
- Endocrinology Section, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL 33125, USA; Department of Medicine, University of Miami Miller School of Medicine, Miami, FL 33101, USA
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Abstract
Postmenopausal osteoporosis is a condition associated with low bone mass resulting from the increased bone resorption that occurs following a decline in estrogen levels. Phytoestrogens are plant-derived compounds that have affinity to the estrogen receptor and are able to act as either estrogen agonists or antagonists. Because of their structural similarity to 17-beta-estradiol, they have been studied extensively for their role in the prevention of postmenopausal bone loss. An extensive number of studies employing different types of isoflavone preparations (including soy foods, soy-enriched foods, and soy isoflavone tablets) have been conducted in a wide range of populations, including Western and Asian women. Although there is considerable variability in study design and duration, study population, type of soy isoflavone employed in the intervention, and study outcomes, the evidence points to a lack of a protective role of soy isoflavones in the prevention of postmenopausal bone loss.
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Affiliation(s)
- Violet S Lagari
- Endocrinology Section, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL, USA; Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
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Abstract
Diet, a modifiable osteoporosis risk factor, plays an important role in the acquisition and maintenance of bone mass. The influence of diet on bone begins in childhood; even maternal diet can influence bone mass in the offspring. A good general nutritional status and adequate dietary protein, calcium, vitamin D, fruits, and vegetables have a positive influence on bone health, while a high caloric diet and heavy alcohol consumption have been associated with lower bone mass and higher rates of fracture. The evidence for a role of other minerals and vitamins in skeletal health is not as strong, but recent evidence suggests that vitamins C and K might also have an effect on bone.
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Affiliation(s)
- Silvina Levis
- Geriatrics Institute, University of Miami Miller School of Medicine, FL 33101, USA.
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Abstract
PURPOSE OF REVIEW The present review summarizes the results of epidemiological studies and clinical trials assessing the skeletal effects of soy foods and soy dietary supplements. RECENT FINDINGS Results from epidemiological studies suggest a beneficial skeletal effect in Asian women consuming typical Asian diets, but clinical trials are conflictive regarding the effects of phytoestrogens on bone mineral density and bone turnover markers in premenopausal and postmenopausal women. Much of the controversy lies in differences in study design, reporting of results, participants' age and menopausal status, and type and dose of phytoestrogen used. SUMMARY Although western women will likely continue to incorporate soy foods and soy supplements into their diets with the increased availability of these products, published data are inconsistent and do not support soy's protective effect against bone loss. This conflicting evidence should be taken into account when considering using isoflavones in the prevention of bone loss and consequently fractures.
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Affiliation(s)
- Violet S Lagari
- Endocrinology Section, Miami Veterans Affairs Medical Center, University of Miami Miller School of Medicine, Miami, Florida, USA
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