Diabetes Fellowship in Primary Care: A Survey of Graduates

Context

The diabetes pandemic has outpaced the US supply of diabetes specialists and has overwhelmed primary care providers (physicians, physician assistants, and nurse practitioners). Primary care diabetes fellowships can be used to address this workforce shortage.

Objectives

To determine the skills obtained during 2 diabetes fellowship programs, the barriers encountered in practice, the impact of the programs on career paths, and perceived acceptance by patients and colleagues.

Methods

A Qualtrics link to a 26-item survey was sent via email to all graduates of the Ohio University Heritage College of Osteopathic Medicine and East Carolina University Brody School of Medicine diabetes fellowship programs. Items included demographic information, comfort level with different clinical diabetes skills, and current system barriers encountered in their practices.

Results

Of 39 graduates, 36 completed the survey. The most beneficial skills acquired during the fellowship were insulin pump management (13 [36%]), insulin management (10 [29%]), and diabetes pharmacology (6 [17%]). The most common barrier was the lack of board certification as a diabetologist, which affected time with patients and insurance reimbursement. The perceived acceptance by patients was high (25 [69%]), and the perceived receptiveness by colleagues was mostly neutral (7 [19%]) or positive (10 [29%]). The most common postfellowship career path was primary care medicine (15) followed by hospitalist (7) and diabetologist (5).

Conclusion

Physicians who completed the diabetes fellowship training reported high comfort levels with treating patients with diabetes, but they also reported the barriers faced in an unrecognized specialty.

Endocrinologists' Opinions of Diabetology as a Primary Care Subspecialty

IN BRIEF This study was conducted to ascertain the opinions of endocrinologists about diabetes care as it relates to the health care provider workforce. A survey was administered to endocrinologists in the Planning Research in Inpatient Diabetes and Planning Research in Outpatient Diabetes (PRIDE/PROUD) group and given to attendees of the American Diabetes Association (ADA) Scientific Sessions special interest group whose focus was primary care. The majority of respondents agreed that there is a need for more providers to be trained to take care of patients with diabetes and that more trained providers are needed, and almost half agreed that primary care providers (PCPs) with advanced training in diabetes should be part of the workforce for managing the diabetes pandemic. Expanding diabetes fellowship programs for PCPs remains an important potential solution for addressing workforce development needs in diabetes care.

Switching basal insulins in type 2 diabetes: practical recommendations for health care providers

Basal insulin remains the mainstay of treatment of type 2 diabetes when diet changes and exercise in combination with oral drugs and other injectable agents are not sufficient to control hyperglycemia. Insulin therapy should be individualized, and several factors influence the choice of basal insulin; these include pharmacological properties, patient preferences, and lifestyle, as well as health insurance plan formularies. The recent availability of basal insulin formulations with longer durations of action has provided further dosing flexibility; however, patients may need to switch agents throughout therapy for a variety of personal, clinical, or economic reasons. Although a unit-to-unit switching approach is usually recommended, this conversion strategy may not be appropriate for all patients and types of insulin. Glycemic control and risk of hypoglycemia must be closely monitored by health care providers during the switching process. In addition, individual changes in care and formulary coverage need to be adequately addressed in order to enable a smooth transition with optimal outcomes.

The Time Is Now: Diabetes Fellowships in the United States

PURPOSE OF REVIEW

Diabetes is a complex and costly chronic disease that is growing at an alarming rate. In the USA, we have a shortage of physicians who are experts in the care of patients with diabetes, traditionally endocrinologists. Therefore, the majority of patients with diabetes are managed by primary care physicians. With the rapid evolution in new diabetes medications and technologies, primary care physicians would benefit from additional focused and intensive training to manage the many aspects of this disease. Diabetes fellowships designed specifically for primary care physicians is one solution to rapidly expand a well-trained workforce in the management of patients with diabetes.

RECENT FINDINGS

There are currently two successful diabetes fellowship programs that meet this need for creating more expert diabetes clinicians and researchers outside of traditional endocrinology fellowships. We review the structure of these programs including funding and curriculum as well as the outcomes of the graduates. The growth of the diabetes epidemic has outpaced current resources for readily accessible expert diabetes clinical care. Diabetes fellowships aimed for primary care physicians are a successful strategy to train diabetes-focused physicians. Expansion of these programs should be encouraged and support to grow the cadre of clinicians with expertise in diabetes care and improve patient access and outcomes.

The role of the new basal insulin analogs in addressing unmet clinical needs in people with type 1 and type 2 diabetes

BACKGROUND

Despite improvements in anti-hyperglycemic therapies, there are many unmet clinical needs that hinder successful glycemic control in people being treated with current basal insulin analogs.

OBJECTIVE

This paper reviews the unmet needs associated with current basal insulin therapy and describes the most recent basal insulins for the treatment of diabetes.

METHODS

PubMed was searched for articles on basal insulin analogs published between 2000 and April 2016.

RESULTS

Although long-acting insulin analogs, such as insulin glargine 100 units/mL and insulin detemir, have come towards approximating physiologic basal insulin levels, limitations such as hypoglycemia and intra- and inter-individual variability are associated with their use resulting in glycemic fluctuations. Some basal insulins lack 24 hour coverage, requiring some patients to split their dose, increasing the number of injections required to maintain glycemic control. Fear of hypoglycemia and the need for additional injections often leads to poor compliance and suboptimal glycemic control. Long-acting insulin analogs, such as insulin glargine 300 units/mL and insulin degludec, have improved upon the shortcomings of the current basal insulin analogs. Improved pharmacodynamic/pharmacokinetic profiles afford lower intra-patient variability and an extended duration of action, providing full and stable 24 hour basal insulin coverage with once daily dosing, and comparable efficacy to insulin glargine with lower rates of hypoglycemia.

CONCLUSION

The improved pharmacodynamic/pharmacokinetic profiles of new long-acting insulin formulations provide greater glycemic control with once daily dosing. With the growing number of therapeutic choices available, physicians have more scope to individualize patient options for basal insulin therapy.

USE OF A COMPUTER-GUIDED GLUCOSE MANAGEMENT SYSTEM TO IMPROVE GLYCEMIC CONTROL AND ADDRESS NATIONAL QUALITY MEASURES: A 7-YEAR, RETROSPECTIVE OBSERVATIONAL STUDY AT A TERTIARY CARE TEACHING HOSPITAL

OBJECTIVE

Inpatient hyperglycemia, hypoglycemia, and glucose variability are associated with increased mortality. The use of an electronic glucose management system (eGMS) to guide intravenous (IV) insulin infusion has been found to significantly improve blood glucose (BG) control. This retrospective observational study evaluated the 7-year (January 2009-December 2015) impact of the EndoTool^® eGMS in intensive and intermediate units at Vidant Medical Center, a 900-bed tertiary teaching hospital.

METHODS

Patients assigned to eGMS had indications for IV insulin infusion, including uncontrolled diabetes, stress hyperglycemia, and/or postoperative BG levels >140 mg/dL. This study evaluated time required to achieve BG control (<180 mg/dL; <140 mg/dL for cardiovascular surgery patients); hypoglycemia incidence (<70 and <40 mg/dL); glucose variability (assessed by SD and coefficient of variation percentage [CV%]); excursions (BG levels >180 mg/dL after control attained); and the impact of eGMS on hospital-acquired condition (HAC)-8 rates.

RESULTS

Data were available for all treated patients (492,078 BG readings from 16,850 patients). With eGMS, BG levels were brought to target within 1.5 to 2.3 hours (4.5 to 4.8 hours for cardiovascular patients). Minimal hypoglycemia was observed (BG values <70 mg/dL, 0.93%; <40 mg/dL, 0.03%), and analysis of variance of BG values <70 mg/dL showed significant reductions over time in hypoglycemia frequency, from 1.04% in 2009 to 0.46% in 2015 (P<.0001). The CV% per patient visit was 26.5 (±12.9)%, and 4% of patients experienced glucose excursions (defined as BG levels >180 mg/dL once control was attained). HAC-8 rates were reduced from 0.083 per 1,000 patients (2008) to 0.032 per 1,000 patients (2011).

CONCLUSION

The use of eGMS resulted in rapid, effective control of inpatient BG levels, including significantly reduced hypoglycemia rates.

ABBREVIATIONS

BG = blood glucose CMS = Centers for Medicare and Medicaid Services CV = coefficient of variation CV% = coefficient of variation percentage eGMS = electronic glucose management system GV = glycemic variability HAC = Hospital-Acquired Condition ICU = intensive care unit IU = intermediate unit IV = intravenous LOS = length of stay VMC = Vidant Medical Center.

Interdisciplinary Diabetes Care: A New Model for Inpatient Diabetes Education

A patient-centered interdisciplinary diabetes care model was implemented at Vidant Medical Center in Greenville, N.C., a 909-bed tertiary care teaching hospital, for the purpose of providing all patients with diabetes clear and concise instructions on diabetes survival skills. Survival skills education during hospitalization is needed for safe transition to community resources for continued and expanded diabetes self-management education. This article describes the process used to develop, implement, and evaluate the model. This initiative achieved substantial cost savings, with no significant changes in length of stay (LOS) or diabetes readmission rates. This patient-centered model demonstrates how a team of interdisciplinary health care professionals can integrate services in providing care for a large population of patients with chronic disease.

The efficacy and safety of DPP4 inhibitors compared to sulfonylureas as add-on therapy to metformin in patients with Type 2 diabetes: A systematic review and meta-analysis

There is no consensus on the selection of specific drug therapies when metformin fails in Type 2 diabetes (T2D). This meta-analysis was performed to determine the efficacy and safety of Dipeptidyl peptidase-4 inhibitors (DPP4-I) compared to sulfonylurea (SU) as add-on therapy to metformin in inadequately controlled T2D patients. We searched MEDLINE, CENTRAL, EMBASE, and CINAHL for randomized trials comparing DPP4-I to SU as add-on therapy to metformin and reported a change in hemoglobin A1c (HbA1c). Sixteen articles were included. There was a significantly greater reduction in HbA1c from baseline to 12 weeks with SU versus DPP4-I (MD[95% CI]=0.21%(2 mmol/mol) [0.06, 0.35]) but no significant difference at 52 and 104 weeks (MD[95% CI]=0.06%(-1 mmol/mol) [-0.03, 0.15] and 0.02%(-1 mmol/mol) [-0.13,0.18] respectively). SU was associated with weight gain and DPP4-I with weight loss at all time-points. The incidence of hypoglycemia at 12, 52, and 104 weeks was significantly greater with SU (20%, 24%, and 27% respectively) compared to DPP4-I (6%, 3%, and 4% respectively). The proportion of patients with HbA1c<7%(53 mmol/mol) without hypoglycemia was significantly higher at 52 and 104 weeks among patients on DPP4-I (RR[95% CI]=1.20 [1.05, 1.37] and 1.53 [1.16, 2.02] respectively). There was no significant difference between the two groups in the incidence of other side effects. While both SU and DPP4-I can be considered as options for add-on therapy to metformin in inadequately controlled T2D, SU results in a significantly increased risk of hypoglycemia and weight gain. By contrast, DPP4-I produce 0.4-0.6% (4-7 mmol/mol) reduction in HbA1c, lower risk of hypoglycemia, and weight loss.

Comparative safety and tolerability of duloxetine vs. pregabalin vs. duloxetine plus gabapentin in patients with diabetic peripheral neuropathic pain

OBJECTIVE

The safety and tolerability of three treatments for diabetic peripheral neuropathic pain (DPNP) were compared.

METHODS

A 12-week, randomized, open-label study confirming the non-inferiority of duloxetine (N = 138) vs. pregabalin (N = 134) and the combination of duloxetine plus gabapentin (N = 135) as the primary outcome was previously published. Patients had an inadequate pain response to a stable dose of gabapentin (≥ 900 mg/day) for ≥ 5 weeks prior to study enrolment. Data from that study were assessed in this current analysis for a detailed report of safety and tolerability.

RESULTS

Completion rates did not differ significantly between the groups. Discontinuation because of adverse events was significantly greater in the duloxetine (19.6%) vs. pregabalin group (10.4%; p = 0.04); no differences emerged between the duloxetine vs. duloxetine plus gabapentin (13.3%) groups (p = 0.19) or pregabalin vs. duloxetine plus gabapentin groups (p = 0.57). Adverse event rates varied: nausea, insomnia, hyperhidrosis and decreased appetite were reported significantly more often in patients treated with duloxetine vs. patients treated with pregabalin (each p ≤ 0.01); insomnia significantly more in patients treated with duloxetine vs. duloxetine plus gabapentin (p = 0.01); peripheral oedema significantly more in patients treated with pregabalin vs. duloxetine and duloxetine plus gabapentin (p ≤ 0.001 each) and nausea, hyperhidrosis, decreased appetite and vomiting significantly more in patients treated with duloxetine plus gabapentin vs. pregabalin (each p ≤ 0.05). At end-point, weight change differed significantly among treatment groups: patients in the pregabalin group on average gained weight (1.0 ± 0.04 kg); while, patients in the duloxetine and duloxetine plus gabapentin groups on average lost weight (-2.39 ± 0.04 and -1.06 ± 0.04 kg, respectively) (pregabalin vs. duloxetine, p ≤ 0.001; pregabalin vs. duloxetine plus gabapentin, p ≤ 0.001; duloxetine vs. duloxetine plus gabapentin, p = 0.01).

CONCLUSION

Duloxetine, pregabalin and duloxetine plus gabapentin were generally safe and tolerable for the treatment of DPNP.

Increased glycemic variability is independently associated with length of stay and mortality in noncritically ill hospitalized patients

OBJECTIVE

To investigate the association between glycemic variability (GV) and both length of stay (LOS) and 90-day mortality in noncritically ill hospitalized patients.

RESEARCH DESIGN AND METHODS

This study retrospectively analyzed 4,262 admissions to the general medicine or surgery services during a 2 year period. Patients with point-of-care glucose monitoring and a minimum of two glucose values per day on average were selected. GV was assessed by SD and coefficient of variation (CV). Data were analyzed with linear and logistic multivariate regression analysis in separate models for SD and CV. Analysis was performed with generalized estimating equations to adjust for correlation between multiple admissions in some individual cases.

RESULTS

After exclusions, 935 admissions comprised the sample. Results of adjusted analysis indicate that for every 10 mg/dL increase in SD and 10-percentage point increase in CV, LOS increased by 4.4 and 9.7%, respectively. Relative risk of death in 90 days also increased by 8% for every 10-mg/dL increase in SD. These associations were independent of age, race, service of care (medicine or surgery), previous diagnosis of diabetes, HbA1c, BMI, the use of regular insulin as a sole regimen, mean glucose, and hypoglycemia occurrence during the hospitalization.

CONCLUSIONS

Our results indicate that increased GV during hospitalization is independently associated with longer LOS and increased mortality in noncritically ill patients. Prospective studies with continuous glucose monitoring are necessary to investigate this association thoroughly and to generate therapeutic strategies targeted at decreasing GV.

Pharmacologic management of diabetic peripheral neuropathic pain

INTRODUCTION

Diabetic peripheral neuropathic pain (DPNP) is a debilitating and distressing complication that occurs in patients with diabetes mellitus. This article provides an overview of diabetic peripheral neuropathy focusing on DPNP.

AREAS COVERED

This article reviews the diagnosis, pathogenesis, prevention and treatment of diabetic neuropathy and neuropathic pain. A comprehensive and systematic Medline search of the published literature for treatment of diabetic peripheral neuropathy was done from 1965 to December 2012. Studies not in English language were excluded.

EXPERT OPINION

Neuropathic pain is difficult to treat, and patients rarely experience complete pain relief. Despite several pharmacological agents being used in the treatment of DPNP, only duloxetine and pregabalin have evidence-based support for controlling DPNP.

GLP-1 response to a mixed meal: what happens 10 years after Roux-en-Y gastric bypass (RYGB)?

BACKGROUND

Oral meal consumption increases glucagon-like peptide 1 (GLP-1) release which maintains euglycemia by increasing insulin secretion. This effect is exaggerated during short-term follow-up of Roux-en-y gastric bypass (RYGB). We examined the durability of this effect in patient with type 2 diabetes (T2DM) >10 years after RYGB.

METHODS

GLP-1 response to a mixed meal in the 10-year post-RYGB group (n = 5) was compared to lean (n = 9), obese (n = 6), and type 2 diabetic (n = 10) controls using a cross-sectional study design. Analysis of variance (ANOVA) was used to evaluate GLP-1 response to mixed meal consumption from 0 to 300 min, 0-20 min, 20-60 min, and 60-300 min, respectively. Weight, insulin resistance, and T2DM were also assessed.

RESULTS

GLP-1 response 0-300 min in the 10-year post-RYGB showed a statistically significant overall difference (p =  0.01) compared to controls. Furthermore, GLP-1 response 0-20 min in the 10-year post-RYGB group showed a very rapid statistically significant rise (p = 0.035) to a peak of 40 pM. GLP-1 response between 20 and 60 min showed a rapid statistically significant (p = 0.041) decline in GLP-1 response from ~40 pM to 10 pM. GLP-1 response in the 10-year post-RYGB group from 60 to 300 min showed no statistically significant difference from controls. BMI, HOMA, and fasting serum glucose before and >10 years after RYGB changed from 59.9 → 40.4, 8.7 → 0.88, and 155.2 → 87.6 mg/dl, respectively, and were statistically significant (p < 0.05).

CONCLUSIONS

An exaggerated GLP-1 response was noted 10 years after RYGB, strongly suggesting a durability of this effect. This phenomenon may play a key role in maintaining type 2 diabetes remission and weight loss after RYGB.

A stepwise approach to insulin therapy in patients with type 2 diabetes mellitus and basal insulin treatment failure

OBJECTIVE

To determine whether 1 or 2 preprandial injections before the meals of greatest glycemic impact can be as effective as 3 preprandial injections in patients with type 2 diabetes mellitus and basal insulin treatment failure.

METHODS

This was an open-label, parallel-group, 1:1:1 randomized study of adults with type 2 diabetes mellitus on oral antidiabetic drugs with glycated hemoglobin (A1C) levels of 8.0% or greater. After a 14-week run-in with insulin glargine, patients with an A1C level greater than 7.0% were randomly assigned to 1, 2, or 3 time(s) daily insulin glulisine for 24 weeks. Changes in A1C from randomization to study end; percentage of patients achieving an A1C level less than 7.0%; changes in A1C, fasting glucose concentrations, and weight at individual study points; and safety (adverse events and hypoglycemia) were assessed throughout the study.

RESULTS

Three hundred forty-three of 631 patients (54%) completing the run-in phase with insulin glargine were randomly assigned to treatment arms. During the randomization phase, A1C reductions with insulin glulisine once or twice daily were noninferior to insulin glulisine 3 times daily (confidence intervals: -0.39 to 0.36 and -0.30 to 0.43; P>.5 for both). However, more patients met the target A1C with 3 preprandial injections (46 [46%]) than with 2 injections (34 [33%]) or 1 injection (30 [30%]). Severe hypoglycemia occurred in twice as many patients receiving 3 preprandial injections (16%) compared with those receiving 2 injections (8%) and 1 injection (7%), but these differences did not reach significance.

CONCLUSION

This study provides evidence that initiation of prandial insulin in a simplified stepwise approach is an effective alternative to the current routine 3 preprandial injection basal-bolus approach.

Duloxetine, pregabalin, and duloxetine plus gabapentin for diabetic peripheral neuropathic pain management in patients with inadequate pain response to gabapentin: an open-label, randomized, noninferiority comparison

OBJECTIVE

To determine whether duloxetine is noninferior to (as good as) pregabalin in the treatment of pain associated with diabetic peripheral neuropathy.

PATIENTS AND METHODS

We performed a 12-week, open-label study of patients with diabetic peripheral neuropathic pain who had been treated with gabapentin (≥ 900 mg/d) and had an inadequate response (defined as a daily pain score of ≥ 4 on a numerical rating scale [0-10 points]). The first patient was enrolled on September 28, 2006, and the last patient visit occurred on August 26, 2009. Patients were randomized to duloxetine monotherapy (n=138), pregabalin monotherapy (n=134), or a combination of duloxetine and gabapentin (n=135). The primary objective was a noninferiority comparison between duloxetine and pregabalin on improvement in the weekly mean of the diary-based daily pain score (0- to 10-point scale) at end point. Noninferiority would be declared if the mean improvement for duloxetine was no worse than the mean improvement for pregabalin, within statistical variability, by a margin of -0.8 unit.

RESULTS

The mean change in the pain rating at end point was -2.6 for duloxetine and -2.1 for pregabalin. The 97.5% lower confidence limit was a -0.05 difference in means, establishing noninferiority. As to adverse effects, nausea, insomnia, hyperhidrosis, and decreased appetite were more frequent with duloxetine than pregabalin; insomnia, more frequent with duloxetine than duloxetine plus gabapentin; peripheral edema, more frequent with pregabalin than with duloxetine; and nausea, hyperhidrosis, decreased appetite, and vomiting, more frequent with duloxetine plus gabapentin than with pregabalin.

CONCLUSION

Duloxetine was noninferior to pregabalin for the treatment of pain in patients with diabetic peripheral neuropathy who had an inadequate pain response to gabapentin.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00385671.

Baseline predictors of A1C reduction in adults using sensor-augmented pump therapy or multiple daily injection therapy: the STAR 3 experience

BACKGROUND

Baseline characteristics from the adult cohort of a randomized controlled trial comparing sensor-augmented pump (SAP) and multiple daily injection (MDI) therapy were analyzed for significant relationships with -0.5% A1C change at 1 year of therapy without incidence of severe hypoglycemia (defined as A1C benefit).

METHODS

Baseline characteristics were compared with A1C benefit. Statistically significant predictors were analyzed further to determine appropriate cutpoints of relative A1C benefit.

RESULTS

Baseline A1C ≥9.1%, age at randomization ≥36 years, and age at diabetes diagnosis of ≥17 years were associated with a greater SAP benefit relative to MDI than other cutpoints.

CONCLUSIONS

People with type 1 diabetes who had a high A1C and who were older at diagnosis and older at randomization experienced the most benefit from SAP therapy.

Outcomes of Roux-en-Y gastric bypass surgery for severely obese patients with type 1 diabetes: a case series report

Roux-en-Y gastric bypass surgery (RYGB) reverses type 2 diabetes (DM2) in approximately 83% of patients with morbid or severe obesity. This procedure has been performed in small numbers of severely obese patients with type 1 diabetes (DM1), but the impact on glycemic control and insulin requirement in this population has not been widely described. We report three patients with DM1 and severe obesity that underwent RYGB. Weight, glycemic control, and insulin requirements before and one year after the procedure were compared. Significant weight loss was achieved by all three patients but insulin requirements decreased in only 2 patients. In contrast, glycemic control (A1C) remained suboptimal in all three patients up to one year after the surgery. These findings suggest that RYGB leads to important weight loss and positively affects insulin sensitivity. However, reaching optimal glycemic control in patients with DM1 diabetes remains challenging due to persisting insulin deficiency.

Confirmation of hypoglycemia in the "dead-in-bed" syndrome, as captured by a retrospective continuous glucose monitoring system

OBJECTIVE

To report a case that substantiates the presence of hypoglycemia at the time of death of a young man with type 1 diabetes, who was found unresponsive in his undisturbed bed in the morning.

METHODS

We describe a 23-year-old man with a history of type 1 diabetes treated with an insulin pump, who had recurrent severe hypoglycemia. In an effort to understand these episodes better and attempt to eliminate them, a retrospective (non-real-time) continuous subcutaneous glucose monitoring system (CGMS) was attached to the patient. He was found dead in his undisturbed bed 20 hours later. The insulin pump and CGMS were both downloaded for postmortem study.

RESULTS

Postmortem download of the data in the CGMS demonstrated glucose levels below 30 mg/dL around the time of his death, with only a minimal counter-regulatory response. This finding corresponded to a postmortem vitreous humor glucose of 25 mg/dL. An autopsy showed no major anatomic abnormalities that could have contributed to his death.

CONCLUSION

To our knowledge, this is the first documentation of hypoglycemia at the time of death in a patient with the "dead-in-bed" syndrome. This report should raise the awareness of physicians to the potentially lethal effects of hypoglycemia and provide justification for efforts directed at avoiding nocturnal hypoglycemia.

Primary care fellowship in diabetes: an innovative program in postgraduate diabetes education

BACKGROUND

To address the need of caring for the growing number of patients with diabetes, East Carolina University implemented a 1-year fellowship in diabetes. Most of the region has been designated as Health Professional Shortage Areas.

DESCRIPTION

The objective of the fellowship is to educate primary care physicians to serve as regional specialists in diabetes. The program is administered by physicians, educators, and representatives of the university's affiliated teaching hospital. The curriculum includes clinical, didactic, and experiential learning strategies in outpatient and inpatient settings. Adult and pediatric endocrinologists, obstetricians, and generalists mentor and evaluate the fellows.

EVALUATION

This innovative training program has improved the availability of high-quality diabetes care for underserved patients in the region. Mean glycemic control in fellows' patients improved and other clinical endpoints were also met.

CONCLUSIONS

A 1-year diabetes fellowship is a replicable solution to address the need for diabetes care specialists.

Acute myocardial infarction attributable to adrenergic crises in a patient with pheochromocytoma and neurofibromatosis 1

OBJECTIVE

To describe a rare case of acute myocardial infarction in a patient with neurofibromatosis 1 and pheochromocytoma and to review the literature on the coexistence of these 2 diseases, the causes of myocardial injury in patients with pheochromocytoma, and the utility of genetic testing and pheochromocytoma screening for those patients and their families.

METHODS

We present a case report, including the detailed clinical, laboratory, and radiographic data, results of adrenal mass pathology, and results of coronary angiography. We also survey other relevant reports available in the literature.

RESULTS

A 43-year-old woman with a history of long-standing hypertension, neurofibromatosis 1, headaches, sweating, and palpitations presented to the hospital with chest pain and shortness of breath. She was found to have an acute myocardial infarction and pulmonary edema, as well as a right adrenal mass. A pheochromocytoma was suspected, and phenoxybenzamine was added to her treatment regimen. Cardiac catheterization showed nonobstructive coronary disease. The levels of plasma catecholamine metabolites were extremely high. The patient underwent uncomplicated laparoscopic right adrenalectomy 2 weeks after this admission. Surgical pathology confirmed the diagnosis of pheochromocytoma.

CONCLUSION

Adrenergic crisis attributable to pheochromocytoma can result in acute myocardial infarction even in the absence of obstructive coronary disease. Inclusion of pheochromocytoma in the differential diagnosis of hypertension in patients with neurofibromatosis is very important and helps avoid mistakes in the management of such patients.

Peptide-YY levels after a fat load in black and white women

OBJECTIVE

To determine whether basal plasma peptide-YY (PYY) levels in overweight, middle-aged black women are different from those of white women of similar BMI and age and ascertain whether there is a difference between the two groups in plasma PYY levels in response to a liquid high fat load.

RESEARCH METHODS AND PROCEDURES

Using a commercial radioimmunoassay kit, the concentration of PYY was measured at baseline and at 2, 4, 6, and 8 hours after ingesting a fatty liquid meal (86.5% of the calories from fat) in 12 black and 12 white women who were matched for age and BMI.

RESULTS

PYY levels (picograms per milliliter) at baseline and at every other time-point of the test meal were significantly lower in the black than in the white group. In addition, the change in PYY concentration from baseline was lower in the black than in the white group only at 8 hours after the meal.

DISCUSSION

The lower baseline level and the blunted PYY response of the black women to the fat load indicated that this signal for appetite suppression was reduced, which, in turn, might contribute to the enhanced obesity of the black women.

Transitioning pharmacologic therapy from oral agents to insulin for type 2 diabetes

Prospective intervention trials using an intensive therapy approach in patients with either type 1 or type 2 diabetes have provided evidence that achieving tight glycemic control can impede the development and progression of microvascular complications. Treatment of type 2 diabetic patients has revolved around the use of oral agents to improve insulin secretion or tissue sensitization. As therapy turns to the inclusion of insulin - most often in combination with oral agents - the physician and patient must both be prepared for the issues regarding management of an injectable agent. The objective of this article is to review current evidence supporting the benefits of adding insulin therapy to existing oral hypoglycemic regimens of patients for whom these therapies are no longer providing adequate glycemic control. Approaches to initiating insulin therapy and adjusting treatment regimens are discussed, with a view towards making the addition or switch to insulin a simple and achievable next step in treatment.

Prevention of foot ulcers in patients with diabetes and end stage renal disease

This quasi-experimental pilot study used a convenience sample of 23 adult men and women with either Type 1 or Type 2 diabetes who received hemodialysis three times a week. The experimental group received a four-part intervention that included individual and group foot care education, foot assessment, and special shoes. Pre- and posttesting of foot care knowledge was done using the Siriraj questionnaire. Out of a possible score of 20, those in the experimental group had a mean score of 15.3 versus 14.33 in the control group on the posttest. The nephrology nurse has the opportunity to play a role in early detection and intervention in clients with ESRD.

Ethnic differences in postprandial triglyceride response to a fatty meal and lipoprotein lipase in lean and obese African American and Caucasian women

The purpose of this study was to determine if there were differences in the expression of lipoprotein lipase (LPL) in African American (AA) and Caucasian (CA) women. LPL mRNA and protein levels were determined in subcutaneous and omental fat of lean and obese subject from the 2 races (4 groups; 12 to 15 subjects/group). LPL mRNA levels of lean AA were not different from the lean CA women in either fat depot. LPL mRNA levels in the subcutaneous fat of the obese AA were higher than those of CA women (1.3 +/- 0.1 v 0.86 +/- 0.06, P.05), but not different in omental fat. LPL mass in subcutaneous fat of lean AA was higher (0.95 +/- 0.09 v 0.64 +/- 0.06, P.05), but not different in omental fat from the CA women. LPL mass in subcutaneous and omental fat was not different in the 2 obese groups. Differences in the activity of LPL were evaluated by (1) measuring the increments of triglycerides (TG) at 2, 4, 6, and 8 hours after a fat-rich meal and (2) by measuring postheparin plasma lipolytic activity. Plasma TG levels in the lean AA were lower than those of the lean CA women at basal and at 2, 4, 6, and 8 hours postprandially. The increase in TG levels at 2 hours tended to be lower in the AA than the CA women, was significantly lower at 4 hours (24 +/- 5 v 45 +/- 7, P.05), and was not different 8 hours postprandially. No differences were observed in either the absolute or the incremental concentrations of TG in the obese groups. Postheparin plasma LPL activity was higher in the lean AA than the lean CA women (4.8 +/- 0.4 v 3.4 +/- 0.4, P.05), but not different in the obese groups. These results indicate that the lower TG concentrations in the lean AA women may be partly due to enhanced expression, activity, and intravascular availability of LPL. Furthermore, it appears that the racial differences in expression and function of LPL are attenuated with obesity.

Patient-reported experience with Velosulin human insulin in continuous subcutaneous insulin infusion

A multicenter, retrospective survey of 339 patients with insulin-dependent diabetes mellitus was done to evaluate patient experience with Velosulin Human insulin, a regular insulin in a phosphate buffer, used in continuous subcutaneous insulin infusion. Patients had used this insulin exclusively for 3 months preceding the survey. Responses were elicited through interviews conducted by physicians or nurses. Patients were queried as to the occurrence of specific complications associated with pump therapy that occurred while using Velosulin Human insulin, including hypoglycemia, diabetic ketoacidosis, unexplained hyperglycemia, tubing obstruction, and infection or abscess at the infusion site. Most patients reported that they did not experience any of these complications during the preceding 3 months. The most frequently cited complication was hyperglycemia unexplained by dosage, exercise, or dietary changes, reported by 110 (32%) patients. The second most frequently reported complication was tubing obstruction, reported by 99 (29%) patients. The reported frequencies of the other complications were: severe hypoglycemia, 45 (13%) patients; diabetic ketoacidosis, 28 (8%) patients; and infection or abscess at the infusion site, 26 (8%) patients. The low morbidity reported by the patients in this survey probably was due in large part to careful patient selection, a high level of motivation on the part of the patients, and experience and education on the part of the health care team, as well as to the use of buffered regular human insulin.

Alterations of plasma opioid activity in human diabetics

Plasma opioid levels were determined in 9 obese non-diabetic subjects, their 8 age matched controls, and in 29 diabetic patients; 10 maintained on diet alone, 6 on an oral hypoglycemic agent (chlorpropamide) and 13 treated with insulin. Five age matched controls for the diabetic groups were also studied for comparison. beta-endorphin and met-enkephalin levels were measured by radioimmunoassay. Enkephalin-like activity was measured by a receptor assay. Among the study groups, diabetic patients receiving insulin showed a 64% elevation of plasma beta-endorphins and diabetic patients on chlorpropamide showed a 121% increase in enkephalin-like activity. There were no statistically significant differences in the plasma met-enkephalin values in the treatment groups though levels were decreased (p less than 0.05) in diabetics vs non-diabetics. The pathophysiological importance of these alterations remains to be elucidated.

Hyperparathyroid crisis and acute necrotizing pancreatitis presenting as diabetic ketoacidosis

The case history of a patient who presented with diabetic ketoacidosis and was subsequently found to have hyperparathyroid crisis complicated by acute necrotizing pancreatitis and phosphate depletion syndrome is reviewed. The interaction of these diseases and their treatment is discussed. The simultaneous presentation of hyperparathyroid crisis and acute necrotizing pancreatitis is rare, and no instance of survival has been reported previously.

Pancreatic alpha cell response to alanine during and after normal and diabetic pregnancies

Pancreatic alpha cell response to oral alanine was assessed in the third trimester of pregnancy and in the puerperium in 16 insulin-dependent diabetic and 7 normal pegnant women. Insulin response was also measured in the nondiabetic subjects. The nondiabetic subjects had higher basal glucagon and insulin levels as well as a greater response to oral alanine stimulation at 34 weeks' gestation than at 6 weeks post partum. In addition, basal levels of both hormones remained low at a time remote from pregnancy (9 months post partum), indicating both hyperinsulinemia and hyperglucagonemia in the postabsorptive state in normal human pregnancy. The secretory response of glucagon and insulin or oral alanine was blunted at 6 weeks post partum in the nondiabetic subjects. This suggests that the late puerperium may not be an appropriate "nonpregnant control period" for metabolic studies. During pregnancy, basal and stimulated glucagon levels were not significantly different in diabetic and normal women. Despite higher concentrations of blood glucose in diabetic women, basal and stimulated glucagon secretion was equivalent in the 2 groups. No pegnancy-induced increment in glucagon secretion was evident in insulin-treated diabetic subjects. Thus hyperglucagonemia does not contribute to the increased requirements for insulin during pregnancy in these women.

Serotoninergic activation and inhibition: effects on carbohydrate tolerance and plasma insulin and glucagon

Glucose and arginine infusion tests were performed on 12 healthy volunteers (8 males, 4 females) before and after serotoninergic activation [oral administration of L-5-hydroxytryptophan (5-HTP-) for 6 days] and serotoninergic inhibition (oral treatment with D,L-p-chloropenylalanine for 6 days). 5-HTP treatment markedly increased urinary 5-hydroxyindoleacetic acid excretion, increased the mild hyperglycemic effect of arginine infusion, and lowered the glucose disposal rate constant. The adverse effect of serotoninergic activation on glucose tolerance is not sufficiently explained by the observed changes in insulin and glucagon secretion during the fasting state and after intravenous glucose and arginine infusions. Serotoninergic inhibition did not affect the carbohydrate tolerance of normal individuals. The results of this work supports the idea that excessive indoleamine production is probably the main cause for carbohydrate intolerance in carcinoid tumors.

Lack of glucagon response to hypoglycemia in diabetic autonomic neuropathy

Glucagon response to insulin hypoglycemia was tested in diabetics with autonomic neuropathy (N=9), diabetics without neuropathy (N=8), and normals (N=9). With similar levels of hypoglycemia, growth hormone and plasma cortisol increased in all groups. The glucagon response in normals (121+/-19 vs. 308+/-30 pg./ml., mean+/-S.E.M. of baseline vs. hypoglycemia peak) was significantly less in nonneuropathic diabetics than in normals (128+/-13 vs. 209+/-30) and absent in neuropathic diabetes (128+/-23 vs. 115+/-20). Arginine stimulation produced a glucagon response in the neuropathic diabetics (106+/-16 vs. 523+/-103). The data indicate that the capacity to release glucagon during hypoglycemia is lost in diabetic neuropathy while glucagon responsiveness to arginine is retained. Neuropathy in diabetes may contribute to metabolic instability.