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Credentials

Education ?

Medical School Score
Wayne State University (1985)
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Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Diabetes Mellitus
Type 2 Diabetes
Castle Connolly's Top Doctors™ (2012 - 2013)
Associations
American Association of Clinical Endocrinologists
American Board of Internal Medicine
Hormone Foundation

Affiliations ?

Dr. Cook is affiliated with 3 hospitals.

Hospital Affiliations

Score

Rankings

  • Mayo Clinic Hospital
    5777 E Mayo Blvd, Phoenix, AZ 85054
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    Top 25%
  • Mayo Clinic - Arizona
    13400 E Shea Blvd, Scottsdale, AZ 85259
  • Mayo Clinic - Phoenix *
  • * This information was reported to Vitals by the doctor or doctor's office.

    Publications & Research

    Dr. Cook has contributed to 108 publications.
    Title A Disposable Tear Glucose Biosensor--part 3: Assessment of Enzymatic Specificity.
    Date February 2012
    Journal Journal of Diabetes Science and Technology
    Excerpt

    A concept for a tear glucose sensor based on amperometric measurement of enzymatic oxidation of glucose was previously presented, using glucose dehydrogenase flavin adenine dinucleotide (GDH-FAD) as the enzyme. Glucose dehydrogenase flavin adenine dinucleotide is further characterized in this article and evaluated for suitability in glucose-sensing applications in purified tear-like saline, with specific attention to the effect of interfering substances only. These interferents are specifically saccharides that could interact with the enzymatic activity seen in the sensor's performance.

    Title Development of a Novel Single Sensor Multiplexed Marker Assay.
    Date July 2011
    Journal The Analyst
    Excerpt

    There is an increasing desire to measure multiple analytes simultaneously for disease management and detection. However, in the case of invasive devices, it would be better to obtain one small sample and immediately be able to detect the analytes rapidly, as in the case of self-monitoring blood glucose, without the need for additional steps, arrays, or reagents. Electrochemical impedance spectroscopy is used to measure the interaction between ultralow levels of analyte and molecular recognition element in a label-free and rapid manner. Gold nanoparticles were attached to antibodies against interleukin-12 and tumor necrosis factor-α, typical inflammatory markers found with near overlapping responses, on an impedance spectroscopy based biosensor. Cross-reactivity and specificity of tuned antibodies were verified using ELISA. Impedance frequency was quantified by concentration gradients of marker against the device. The natural impedance frequency for interleukin-12 (5.00 Hz) was tuned to a lower frequency four Hertz away from one another for better signal processing. This was accomplished without significantly altering the lower limits of detection (<4 pg ml(-1) and ∼60 pg ml(-1) for interleukin-12 and tumor necrosis factor-α, respectively), no cross-reactivity and specificity as determined by ELISAs. With modeling the nanoscale effects and further development, a larger tuning will be possible for making a better multiplexed sensor. Although interleukin-12 and TNF-α equivalent circuit calculations were modeled here, a sensor with the potential to measure multiple markers at once might offer a solution on the sensor front for simplified management of conditions such as diabetes, where both glucose and hemoglobin A1c values could be obtained.

    Title Diabetes in the Desert: What Do Patients Know About the Heat?
    Date February 2011
    Journal Journal of Diabetes Science and Technology
    Excerpt

    This study aims to identify self-management strategies used by patients with diabetes in hot weather, examine knowledge of safe temperatures and exposure times, and evaluate comprehension of weather data.

    Title Relationship Between Inpatient Hyperglycemia and Insulin Treatment After Kidney Transplantation and Future New Onset Diabetes Mellitus.
    Date January 2011
    Journal Clinical Journal of the American Society of Nephrology : Cjasn
    Excerpt

    Approximately two-thirds of kidney transplant recipients with no previous history of diabetes experience inpatient hyperglycemia immediately after kidney transplant surgery; whether inpatient hyperglycemia predicts future new onset diabetes after transplant (NODAT) is not established.

    Title Outpatient-to-inpatient Transition of Insulin Pump Therapy: Successes and Continuing Challenges.
    Date November 2010
    Journal Journal of Diabetes Science and Technology
    Excerpt

    Insulin pump therapy is a complex technology prone to errors when employed in the hospital setting. When patients on insulin pump therapy require hospitalization, practitioners caring for them must decide whether to allow continued pump use. We provide the largest review regarding transitioning insulin pump therapy from the outpatient to inpatient setting.

    Title A Disposable Tear Glucose Biosensor-part 1: Design and Concept Testing.
    Date August 2010
    Journal Journal of Diabetes Science and Technology
    Excerpt

    Tear glucose has been suggested previously as a potential approach for the noninvasive estimation of blood glucose. While the topic remains unresolved, an overview of previous studies suggests the importance of a tear sampling approach and warrants new technology development. A concept device is presented that meets the needs of a tear glucose biosensor.

    Title A Disposable Tear Glucose Biosensor-part 2: System Integration and Model Validation.
    Date August 2010
    Journal Journal of Diabetes Science and Technology
    Excerpt

    We presented a concept for a tear glucose sensor system in an article by Bishop and colleagues in this issue of Journal of Diabetes Science and Technology. A unique solution to collect tear fluid and measure glucose was developed. Individual components were selected, tested, and optimized, and system error modeling was performed. Further data on prototype testing are now provided.

    Title Perceptions of Resident Physicians About Management of Inpatient Hyperglycemia in an Urban Hospital.
    Date November 2009
    Journal Journal of Hospital Medicine : an Official Publication of the Society of Hospital Medicine
    Excerpt

    Information regarding practitioner beliefs about inpatient diabetes care is limited.

    Title Inpatient to Outpatient Transfer of Diabetes Care: Planing for an Effective Hospital Discharge.
    Date July 2009
    Journal Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists
    Excerpt

    To review data on diabetes discharge planning, provide a definition of an effective diabetes discharge, and summarize one institution's diabetes discharge planning processes in a teaching hospital.

    Title Hyperglycemia During the Immediate Period After Kidney Transplantation.
    Date June 2009
    Journal Clinical Journal of the American Society of Nephrology : Cjasn
    Excerpt

    Hyperglycemia and new-onset diabetes occurs frequently after kidney transplantation. The stress of surgery and exposure to immunosuppression medications have metabolic effects and can cause or worsen preexisting hyperglycemia. To our knowledge, hyperglycemia in the immediate posttransplantation period has not been studied.

    Title Beliefs About Hospital Diabetes and Perceived Barriers to Glucose Management Among Inpatient Midlevel Practitioners.
    Date April 2008
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: The purpose of this study is to explore attitudes among inpatient midlevel practitioners about hospital hyperglycemia and to identify perceived barriers to care. METHODS: A questionnaire previously applied to resident physicians was administered to midlevel providers (physician assistants and nurse practitioners) to determine their beliefs about the importance of inpatient glucose control, their perceptions about what glucose ranges were desirable, and the problems they encountered when trying to manage hyperglycemia in the hospital. Barriers to care reported in this study were also combined with responses from the prior resident survey. RESULTS: Most respondents indicated that glucose control was very important in critically ill, noncritically ill, and perioperative patients. However, most felt only somewhat comfortable treating hyperglycemia and hypoglycemia and with using subcutaneous insulin; respondents expressed the least amount of confidence with using insulin infusions and insulin pumps. Respondents were not familiar with existing institutional polices and preprinted order sets relating to glucose management. The most commonly reported barrier to hyperglycemia management in the hospital was lack of familiarity with how to useinsulin, a finding that persisted after analyzing composite resident and midlevel responses. CONCLUSIONS: Most midlevel providers acknowledged the importance of good glucose control in the hospital. Lack of familiarity with how to use insulin in the hospital was the most commonly cited barrier to care. Educational programs should heavily emphasize inpatient treatment strategies.

    Title Inpatient Point-of-care Bedside Glucose Testing: Preliminary Data on Use of Connectivity Informatics to Measure Hospital Glycemic Control.
    Date February 2008
    Journal Diabetes Technology & Therapeutics
    Excerpt

    BACKGROUND: Point-of-care (POC) bedside glucose (BG) testing and timely evaluation of its effectiveness are important components of hospital inpatient glycemic control programs. We describe a new technology to evaluate inpatient POC-BG testing and report preliminary results of inpatient glycemic control from 10 U.S. hospitals. METHODS: We used the Remote Automated Laboratory System RALS-Tight Glycemic Control Module (TGCM) (Medical Automation Systems, Charlottesville, VA) connected to the RALS-Plus to extract and analyze inpatient POC-BG tests from 10 U.S. hospitals for a 3-month period. POC-BG measurements were evaluated in aggregate from all 10 facilities for intensive care unit (ICU), non-ICU, and ICU + non-ICU combined. RESULTS: A total of 742,154 POC-BGs were analyzed. The combined (ICU + non-ICU) mean POC-BG was 159 mg/dL, compared with 146 mg/dL for the ICU and 164 mg/dL for non-ICU. The proportion of hypoglycemic values (<70 mg/dL) was low at 4%, but the percentage of measurements that would be considered hyperglycemic (>180 mg/dL) was high, with more than 30% of values in the non-ICU and 20% in the ICU being elevated. CONCLUSIONS: POC-BG data can be captured through automated data management software and can support hospital efforts to evaluate and monitor the status of inpatient glycemic control. These preliminary data suggest that there is a need to conduct broad-based efforts to improve inpatient glucose management. Increasing hospital participation in data collection has the potential to create a national benchmarking process for the development of best practices and improved inpatient hyperglycemia management.

    Title Relationship of Diabetes with Cardiovascular Disease-related Hospitalization Rates, Length of Stay, and Charges: Analysis by Race/ethnicity, Age, and Sex.
    Date February 2008
    Journal Ethnicity & Disease
    Excerpt

    OBJECTIVE: Determine relationship of diabetes with risk of cardiovascular disease hospitalizations and the effect on hospital length of stay and charges. DESIGN: A cross-sectional analysis of Georgia hospital discharge data for 1998 through 2001. PATIENTS: Patients hospitalized principally with one of six cardiovascular disease (CVD) conditions (myocardial infarction, ischemic heart disease, cardiac dysrhythmia, heart failure, cerebrovascular events, peripheral vascular disease) were identified in the hospital discharge data. MAIN OUTCOME MEASURES: Aggregated CVD-related hospitalization rates, length of stay, and charges were compared by presence of diabetes. Analyses were adjusted for age, sex, and race/ethnicity. RESULTS: A total of 3,900,337 discharges were recorded between 1998 to 2001. Of these, 468,957 discharges (12%) had one of the six selected CVD diagnoses (average age 67 years, average length of stay 4.7 days, average total charge $15,702, 48% women, 76% non-Hispanic Whites, 22% non-Hispanic Blacks, and 1% Hispanics). Diabetes was a concurrent diagnosis in 30% of these CVD-related discharges. CVD hospitalization rates were significantly higher and length of stay and total charges were significantly greater among non-Hispanic Whites and Blacks-but not in Hispanics-with diabetes compared to persons without diabetes. Diabetes had a similar effect on CVD hospitalizations among men and women, but the effect of diabetes was lessened with increasing age. CONCLUSION: These data suggests that aggressive outpatient modification of metabolic abnormalities in diabetes patients should be attempted to decrease risk of CVD-related hospitalization and lower the economic impact of these combined conditions.

    Title Inpatient to Outpatient Transfer of Diabetes Care: Perceptions of Barriers to Postdischarge Followup in Urban African American Patients.
    Date November 2007
    Journal Ethnicity & Disease
    Excerpt

    OBJECTIVES: To determine potential obstacles to postdischarge followup of hospitalized diabetes patients and to inform planning to better ensure continuity of service when care is transferred from inpatient to outpatient settings. DESIGN: Surveys of hospital inpatients. SETTING: Urban hospital PATIENTS: Inpatients with diabetes mellitus. MAIN OUTCOME MEASURES: Identification of barriers to postdischarge followup in relation to age, sex, race, marital status, employment status, educational level, health insurance status, date of admission, date of diagnosis, admission and discharge glucose values, and hyperglycemia medications at discharge. RESULTS: Of 303 respondents (average age 50 years, 46% women, 91% African American), 95% indicated that they planned to use follow-up services. Fifty percent of these patients anticipated encountering barriers to keeping outpatient appointments. The primary reasons were transportation problems (59%), inability to afford the visit (34%), and lack of health insurance (24%). Among persons expecting difficulty with follow-up care, significantly more were uninsured (P=.025), and a greater proportion had prior trouble accessing medical care (P<.0001). The odds of anticipating a barrier to postdischarge followup were higher for persons without health insurance (odds ratio [OR] 2.62, P=.040) and for persons with prior healthcare access problems (OR 5.94, P<.0001). Women also had a greater chance of reporting an obstacle (OR 2.30, P=.024). CONCLUSION: New discharge planning programs that emphasize the need for long-term followup and that assist persons with access to postdischarge medical services should be developed, particularly for minority populations at particular risk for diabetes and its complications.

    Title Diabetes Care in Hospitalized Noncritically Ill Patients: More Evidence for Clinical Inertia and Negative Therapeutic Momentum.
    Date October 2007
    Journal Journal of Hospital Medicine (online)
    Excerpt

    BACKGROUND: Little is known about management of hyperglycemia in inpatients. OBJECTIVE: To gain insight into caring for hospitalized patients with hyperglycemia. DESIGN: Retrospective analysis. SETTING: Teaching hospital. PATIENTS: Data on all patients discharged between January 1, 2001, and December 31, 2004 with a diagnosis of diabetes or hyperglycemia were extracted and linked to laboratory and pharmacy databases. Only the data on patients who did not require intensive care and who were hospitalized for at least 3 days were analyzed. MEASUREMENTS: Average bedside glucose during the first and last 24 hours of hospital stay and for the entire length of stay; assessment of changes in insulin regimen and dose. RESULTS: The average age of patients included in the study (n = 2916) was 69 years. Fifty-seven percent of the patients were men, 90% were white, and average length of stay was 5.7 days. More than 20% of the patients had evidence of sustained hyperglycemia. Forty-two percent of the patients who showed poor control of glycemia (glucose > 200 mg/dL) during the first 24 hours were discharged in poor control. The frequency of hypoglycemia was low (only 2.2 of 100 measurements per person) compared with hyperglycemia (25.5 of 100 measurements per person). Most patients (72%) received insulin during hospitalization, but there was high use of short-acting insulin and less than optimal intensification of therapy (clinical inertia); many patients had insulin therapy decreased despite persistent hyperglycemia (negative therapeutic momentum). CONCLUSIONS: Glycemic control in the hospital was frequently poor, and there was suboptimal use of insulin, even among patients with sustained hyperglycemia. Educational programs directed at practitioners should focus on the importance of inpatient glucose control and provide guidelines on how and when to change therapy.

    Title Clinical and Bone Density Outcomes of Tumor-induced Osteomalacia After Treatment.
    Date October 2007
    Journal Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists
    Excerpt

    OBJECTIVE: To report the outcomes of tumor-induced osteomalacia after treatment, particularly related to recovery of bone mass. METHODS: We review the clinical course of a 61-year-old man extremely debilitated from multiple fractures and neuromuscular weakness due to tumor-induced osteomalacia and report the changes in biochemical markers and bone density after removal of the causative neoplasm. RESULTS: At the time of diagnosis, the patient's serum phosphorus and 1,25 dihydroxyvitamin D levels were depressed, and his fibroblast growth factor-23 level was markedly elevated. These values normalized 2 days after surgery and remained within their respective reference ranges 4 and 12 months after resection of a mesenchymal tumor. Lumbar bone density values (T-scores) were 0.445 g/cm2 (-5.9) preoperatively, 0.939 g/cm2 (-1.4) 4 months after surgery, and 1.152 g/cm2 (0.7) 12 months after surgery. Left femoral neck values at the same time points were 0.525 g/cm2 (-3.0), 1.035 g/cm2 (-0.8), and 1.184 g/cm2 (1.9). Ultra-distal radius values at the same time points were 0.128 g/cm2 (-7.0), 0.191 g/cm2 (-5.9), and 0.259 g/cm2 (-4.8). In addition, he recovered neuromuscular function and was able to leave his wheelchair. CONCLUSION: Tumor-induced osteomalacia can be an extremely debilitating disease. With successful localization, identification, and resection of the neoplasm, bone mass and physical function can recover.

    Title Common Reasons for Hospitalization in Urban Diabetes Patients.
    Date September 2007
    Journal Ethnicity & Disease
    Excerpt

    OBJECTIVES: Determine principal reasons for hospitalization in a predominantly urban, African American diabetes patient population. DESIGN: Data for outpatients with a diagnosis of diabetes were abstracted from electronic records. The number of hospitalizations from 1998 through 2001 was determined after linking our dataset with a statewide discharge dataset. Principal diagnoses were grouped into 18 multilevel diagnostic classes using the Agency for Healthcare Research and Quality's Clinical Classifications Software. PATIENTS: A total of 6505 unique patients had 20,344 discharges from 1998 through 2001; 92% were listed as African Americans and 61% as women. MAIN OUTCOME MEASURES: Frequency of each multilevel diagnostic class and the most commonly occurring diagnoses. RESULTS: The most common multilevel diagnostic classes were "diseases of the circulatory system" (29.0% of all discharges) and "endocrine, nutritional, and metabolic; immunity disorders" (17.1%). The five most commonly occurring unique diagnoses were "congestive heart failure," "diabetes with ketoacidosis or uncontrolled diabetes," "coronary atherosclerosis," "diabetes with other manifestations," and "pneumonia, organism unspecified." Nearly 16% of all discharged patients had diagnoses related to infection. The five most frequent diagnoses related to infection were "pneumonia, organism unspecified," "urinary tract infection, site not specified," "infection and inflammation, internal prosthetic device," "cellulitis and abscess of leg," and "postoperative infection." CONCLUSIONS: In this predominantly urban, African American diabetes patient population, potentially preventable hospitalizations involving diseases such as congestive heart failure and diabetes occur with high frequency. Better understanding of the risk factors underlying these hospitalizations--particularly those involving modifiable metabolic variables--requires further investigation.

    Title Management of Inpatient Hyperglycemia: Assessing Perceptions and Barriers to Care Among Resident Physicians.
    Date July 2007
    Journal Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists
    Excerpt

    OBJECTIVE: To develop insight into resident physician attitudes about inpatient hyperglycemia and determine perceived barriers to optimal management. METHODS: As part of a planned educational program, a questionnaire was designed and administered to determine the opinions of residents about the importance of inpatient glucose control, their perceptions about what glucose ranges were desirable, and the problems they encountered when trying to manage hyperglycemia in hospitalized patients. RESULTS: Of 70 resident physicians from various services, 52 completed the survey (mean age, 31 years; 48% men; 37% in first year of residency training). Most respondents indicated that glucose control was "very important" in critically ill and perioperative patients but only "somewhat important" in non-critically ill patients. Most residents indicated that they would target a therapeutic glucose range within the recommended levels in published guidelines. Most residents also said they felt "somewhat comfortable" managing hyperglycemia and hypoglycemia and using subcutaneous insulin therapy, whereas most residents (48%) were "not at all comfortable" with use of intravenous administration of insulin. In general, respondents were not very familiar with existing institutional policies and preprinted order sets relating to glucose management. The most commonly reported barrier to management of inpatient hyperglycemia was lack of knowledge about appropriate insulin regimens and how to use them. Anxiety about hypoglycemia was only the third most frequent concern. CONCLUSION: Most residents acknowledged the importance of good glucose control in hospitalized patients and chose target glucose ranges consistent with existing guidelines. Lack of knowledge about insulin treatment options was the most commonly cited barrier to ideal management. Educational programs should emphasize inpatient treatment strategies for glycemic control.

    Title Potentially Modifiable Metabolic Factors and the Risk of Cardiovascular Disease Hospitalizations in Urban African Americans with Diabetes.
    Date July 2007
    Journal Ethnicity & Disease
    Excerpt

    OBJECTIVE: Diabetes and cardiovascular disease (CVD) are frequent causes of hospitalization in African Americans but have rarely been studied as coexisting diagnoses. We analyzed data from an urban African American diabetes patient population to identify variables associated with CVD hospitalizations. DESIGN: Demographic, disease, and metabolic characteristics of patients seen from 1991 to 1997 were extracted from an electronic patient tracking system. Data were linked to a statewide hospital discharge dataset to establish who was hospitalized between 1998 and 2001. Patients with a CVD hospitalization were compared to patients without a CVD hospitalization. RESULTS: 3397 diabetes patients (average age, 56 years; 65% women; 92% African American) were included in the analysis; 24% had hospitalizations primarily due to CVD. Persons with CVD hospitalizations were older and had diabetes longer, and fewer were women. Mean systolic blood pressure (SBP), low-density lipoprotein (LDL) cholesterol, triglyceride, and total cholesterol levels and urinary albumin/creatinine ratio were all higher among persons with CVD hospitalizations. In adjusted analyses, women had lower odds of experiencing a CVD hospitalization, but advancing age, diabetes duration, SBP, and LDL cholesterol were all associated with greater odds. CONCLUSIONS: In this predominantly African American patient sample with diabetes, specific factors (age, sex, diabetes duration, LDL cholesterol, SBP) were associated with CVD hospitalizations. Additional studies are needed to determine whether management of metabolic risk factors in outpatient settings will translate into lower hospitalization rates due to CVD in this population.

    Title Poor Glycemic Control Increases Risk of Hospitalization in Urban African Americans with Diabetes.
    Date July 2007
    Journal Ethnicity & Disease
    Excerpt

    OBJECTIVE: Hospitalizations due to diabetes are more frequent among African Americans, but risk factors are not known. We analyzed data from an urban African American patient population to identify variables associated with hospitalizations attributable principally to diabetes. DESIGN: Demographic, disease, and metabolic characteristics on patients seen in an outpatient diabetes clinic during 1991 to 1997 were extracted from an electronic patient tracking system. Data were linked to a statewide hospital discharge dataset to capture all in-state hospitalizations from 1998 to 2001. Persons who required a hospitalization for diabetes were compared to the remainder of individuals in the database. RESULTS: A total of 3397 diabetes patients (average age 56 years; 65% women; 92% African American) were included in the analysis; 12% had a hospitalization primarily due to diabetes. Persons with a diabetes hospitalization were younger and had diabetes longer, and fewer were women. In addition, persons who had a diabetes-related hospitalization had evidence of poorer glycemic control with higher hemoglobin A1C (HbA1C) levels. Both the absolute change and rate of decline in HbA1C was less in persons who were hospitalized. In adjusted analyses, duration of diabetes and HbA1C remained significantly associated with risk of a diabetes hospitalization. CONCLUSIONS: In this predominantly African American patient sample with diabetes, poorer glycemic control increased the chances of hospitalization due to diabetes. Continued efforts to aggressively control hyperglycemia could decrease the need for a diabetes hospitalization in this population.

    Title Improving Point Predictions of Random Effects for Subjects at High Risk.
    Date April 2007
    Journal Statistics in Medicine
    Excerpt

    The prediction of random effects corresponding to subject-specific characteristics (e.g. means or rates of change) can be very useful in medical and epidemiologic research. At times, one may be most interested in obtaining accurate and/or precise predictions for subjects whose characteristic places them in a tail of the distribution. While the typical posterior mean predictor dominates others in terms of overall mean squared error of prediction (MSEP), its tendency to 'overshrink' has motivated research into alternatives emphasizing other criteria. Here, we specifically target MSEP within a certain region (e.g. above a known cut-off for high risk or a specified percentile of the random effect distribution), and we consider minimizing this quantity with and without constraints on overall MSEP efficiency. We use the normal-theory random intercept model to derive prediction methods with potential to yield markedly better performance for subjects in the specified region, given a well-controlled and (if desired) modest concession of overall MSEP. Criteria geared toward classification as well as overall and regional prediction unbiasedness are also provided. We evaluate the proposed techniques and illustrate them using repeated measures data on fasting blood glucose from type 2 diabetes patients. A simulation study verifies that theoretical properties and relative performances of the proposed predictors are essentially maintained when calculating them in practice based on estimated mixed linear model parameters. Straightforward extensions to incorporate covariates and additional random effects are briefly outlined.

    Title Working to Improve Care of Hospital Hyperglycemia Through Statewide Collaboration: the Georgia Hospital Association Diabetes Special Interest Group.
    Date April 2007
    Journal Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists
    Excerpt

    OBJECTIVE: To review the efforts of the Georgia Hospital Association Diabetes Special Interest Group (DSIG) to develop and disseminate sample clinical guidelines on management of inpatient hyperglycemia. METHODS: Beginning in February 2003, a consortium of physicians and allied health professionals from throughout the state of Georgia began meeting on a frequent basis to formulate a plan to enhance the care of hospitalized patients with hyperglycemia. The immediate goals of the DSIG were the identification and organization of interested stakeholders, the development of consensus sample clinical guidelines, and the dissemination of information. RESULTS: Since its inception, the DSIG has accomplished the following: development of 7 consensus sample clinical guidelines, construction of a Web site that posts these clinical guidelines and other useful related information and educational materials, and sponsorship of workshops throughout the state of Georgia. CONCLUSION: As the importance of glucose control in the hospital setting has become increasingly recognized, institutions must find ways of applying results of clinical trials to "real-world" hospital environments. The DSIG is an example of a successful collaboration that could serve as a model for other state hospital organizations that wish to develop programs to enhance the care of inpatients with hyperglycemia.

    Title Diabetes Care in the Hospital: is There Clinical Inertia?
    Date March 2007
    Journal Journal of Hospital Medicine : an Official Publication of the Society of Hospital Medicine
    Excerpt

    BACKGROUND: Effective control of hospital glucose improves outcomes, but little is known about hospital management of diabetes. OBJECTIVE: Assess hospital-based diabetes care delivery. DESIGN: Retrospective chart review. SETTING: Academic teaching hospital. PATIENTS: Inpatients with a discharge diagnosis of diabetes or hyperglycemia were selected from electronic records. A random sample (5%, n = 90) was selected for chart review. MEASUREMENTS: We determined the percentage of patients with diabetes or hyperglycemia documented in admission, daily progress, and discharge notes. We determined the proportion of cases with glucose levels documented in daily progress notes and with changes in hyperglycemia therapy recorded. The frequency of hypoglycemic and hyperglycemic events was also determined. RESULTS: A diabetes diagnosis was recorded at admission in 96% of patients with preexisting disease, but daily progress notes mentioned diabetes in only 62% of cases and 60% of discharge notes; just 20% of discharges indicated a plan for diabetes follow-up. Most patients (86%) had bedside glucose measurements ordered, but progress notes tracked values for only 53%, and only 52% had a documented assessment of glucose severity. Hypoglycemic events were rare (11% of patients had at least one bedside glucose < 70 mg/dL), but hyperglycemia was common (71% of cases had at least one bedside glucose > 200 mg/dL). Despite the frequency of hyperglycemia, only 34% of patients had their therapy changed. CONCLUSIONS: Practitioners were often aware of diabetes at admission, but the problem was often overlooked during hospitalization. The low rate of documentation and therapeutic change suggests the need for interventions to improve provider awareness and enhance inpatient diabetes care.

    Title Common Reasons for Hospitalization Among Adult Patients with Diabetes.
    Date October 2006
    Journal Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists
    Excerpt

    OBJECTIVE: To determine reasons for hospitalization among adult patients with diabetes. METHODS: A cross-sectional analysis was conducted of hospital discharges in the state of Georgia for the years 1998 through 2001 that contained either a primary or a coexisting diagnosis of diabetes. With use of the Clinical Classification Software of the Agency for Healthcare Research and Quality, the principal diagnoses among diabetes-related hospital discharges were organized into diagnostic categories. RESULTS: Diabetes was listed as a diagnosis in 14% of all Georgia hospital discharges of adult patients during our study period (57% women; 62% non-Hispanic white; mean age, 64 years; mean length of stay, 5.7 days; and mean hospital charge, 13,540 dollars). Among patients with a diagnosis of diabetes, the 3 most common categories of discharges were "diseases of the circulatory system" (33%), "endocrine, nutritional, and metabolic; immunity disorders" (13%), and "diseases of the respiratory system: (11%). When infections were identified and aggregated, however, these conditions became the second most frequent discharge category (14% of all hospital discharges among patients with diabetes). "Congestive heart failure," "coronary atherosclerosis," and "acute myocardial infarction" were the first, second, and fifth most frequently found unique diagnoses, respectively, among patients with diabetes. CONCLUSION: In this study, diseases of the circulatory system were the most common diagnoses in hospital discharge data for adult patients with diabetes in Georgia. Hospitals should be cognizant of the increased burden placed on them by diabetes, and outpatient treatment of diabetes should focus on prevention of cardiovascular diseases to avoid hospitalizations.

    Title Use of a Glucose Algorithm to Direct Diabetes Therapy Improves A1c Outcomes and Defines an Approach to Assess Provider Behavior.
    Date September 2006
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: The purpose of this study was to determine whether an algorithm that recommended individualized changes in therapy would help providers to change therapy appropriately and improve glycemic control in their patients. METHODS: The algorithm recommended specific doses of oral agents and insulin based on a patient's medications and glucose or A1C levels at the time of the visit. The prospective observational study analyzed the effect of the algorithm on treatment decisions and A1C levels in patients with type 2 diabetes. RESULTS: The study included 1250 patients seen in pairs of initial and follow-up visits during a 7-month baseline and/or a subsequent 7-month algorithm period. The patients had a mean age of 62 years, body mass index of 33 kg/m(2), duration of diabetes of 10 years, were 94% African American and 71% female, and had average initial A1C level of 7.7%. When the algorithm was available, providers were 45% more likely to intensify therapy when indicated (P = .005) and increased therapy by a 20% greater amount (P < .001). A1C level at follow-up was 90% more likelyto be <7% in the algorithm group, even after adjusting for differences in age, sex, body mass index, race, duration of diabetes and therapy, glucose, and A1C level at the initial visit (P < .001). CONCLUSIONS: Use of an algorithm that recommends patient-specific changes in diabetes medications improves both provider behavior and patient A1C levels and should allow quantitative evaluation of provider actions for that provider's patients.

    Title Improving Hyperglycemia Management in the Intensive Care Unit: Preliminary Report of a Nurse-driven Quality Improvement Project Using a Redesigned Insulin Infusion Algorithm.
    Date August 2006
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: The purpose of this study was to assess the feasibility of a nurse-driven effort to improve hyperglycemia management in the intensive care unit (ICU) setting. METHODS: The setting was the ICU of a large urban hospital. The program was composed of 3 components: nurses as leaders, a clinical pathway to identify patients in need of hyperglycemia therapy, and implementation of a redesigned insulin infusion algorithm (the Columnar Insulin Dosing Chart). Time to reach a target glucose range of 80 to 110 mg/dL (4.4-6.1 mmol/L) was evaluated. RESULTS: One hundred sixteen ICU nurses were trained in the project. The Columnar Insulin Dosing Chart was applied to 20 patients. The average time required to reach the target blood glucose range was 12.8 hours. Below-target blood glucose levels were 6.9% of all blood glucose levels recorded, but only 0.9% were below 60 mg/dL (3.3 mmol/L). There was no sustained hypoglycemia, and no persistent clinical findings attributable to hypoglycemia were noted. Barriers to implementing the project included an increased nursing workload, the need for more finger-stick blood glucose monitors, and the need to acquire new finger-lancing devices that allowed for shallower skin puncture and increased patient comfort. CONCLUSIONS: Tighter glycemic control goals can be attained in a busy ICU by a nurse-led team using a pathway for identifying and treating hyperglycemia, clear decision support tools, and adequate nurse education. The novel chart-based insulin infusion algorithm chosen as the standard for this pilot was an effective tool for reducing the blood glucose to target range with no clinically significant hypoglycemia.

    Title Disparities in Diabetes-related Hospitalizations: Relationship of Age, Sex, and Race/ethnicity with Hospital Discharges, Lengths of Stay, and Direct Inpatient Charges.
    Date June 2006
    Journal Ethnicity & Disease
    Excerpt

    OBJECTIVE: To identify any differences in hospitalization rates of diabetes patients by age, sex, or race/ethnicity. DESIGN: A cross-sectional study of Georgia hospital discharge data between 1998 and 2001. PATIENTS/PARTICIPANTS: Patients with a principal discharge diagnosis of diabetes. MAIN OUTCOME MEASURES: Adjusted hospitalization data (discharge rates, length of stay, direct charges) reported as standardized rates per 10,000 person-years, standardized rate differences, and standardized rate ratios, compared by age, sex, and race/ethnicity. RESULTS: Diabetes was the principal diagnosis in 50,301 discharges (average age, 51 years; length of stay, 5.1 days; median total charge, $5893). Persons > or = 60 years old had higher discharge rates, longer stays, and higher charges than persons 18-29 years old. Women had fewer hospitalizations, shorter stays, and lower charges than men. Non-Hispanic Blacks had more than three times as many hospitalizations, markedly longer stays, and higher charges than non-Hispanic Whites. Hispanics with diabetes had lower hospitalization rates, shorter stays, and lower charges than Whites. CONCLUSIONS: Differences by age, sex, and race/ethnicity in hospital discharge rates, lengths of stay, and charges exist for diabetes inpatients. Further study should examine potential causes (severity of disease, comorbidity, and differential access to preventive care) of these disparities.

    Title An Intervention to Overcome Clinical Inertia and Improve Diabetes Mellitus Control in a Primary Care Setting: Improving Primary Care of African Americans with Diabetes (ipcaad) 8.
    Date March 2006
    Journal Archives of Internal Medicine
    Excerpt

    BACKGROUND: Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated--clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control. METHODS: In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 150 mg/dL (8.33 mmol/L) during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations). RESULTS: At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy were indicated, and there were no differences among intervention groups. During the trial, intensification increased most during the first year and then declined. However, intensification increased more in the feedback alone and feedback plus reminders groups than for reminders alone and control groups (P<.001). After 3 years, health care provider behavior in the reminders alone and control groups returned to baseline, whereas improvement with feedback alone and feedback plus reminders groups was sustained: 52% did anything, and 30% did enough (P<.001 for both vs the reminders alone and control groups). Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c (P<.001 for both). CONCLUSIONS: Feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels. Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care settings.

    Title Diabetes Management by Residents in Training in a Municipal Hospital Primary Care Site (ipcaad 2).
    Date February 2006
    Journal Ethnicity & Disease
    Excerpt

    PURPOSE: Since diabetes is largely a primary care problem but we know little about management by residents in training--the primary care practitioners of the future--we examined surrogate outcomes reflective of their performance. METHODS: A seven-week observational study was conducted in a typical training site- a municipal hospital internal medicine resident "continuity" (primary care) clinic in a large, academic, university-affiliated training program. We evaluated control of glucose, blood pressure, and lipids; screening for proteinuria; and use of aspirin relative to national standards. RESULTS: Five hundred fifty-six (556) patients were 72% female and 97% African-American, with mean age 63 years, duration of diabetes 12 years, and BMI 34 kg/m2. Patients were managed largely with diet alone (22%) or oral agents alone (40%); 7% used oral agents and insulin in combination, and 30% insulin alone. Hemoglobin A1c (mean 8.2%) was above goal (<7.0%) in 61% of patients. Low density lipoprotein cholesterol (mean 128 mg/dL) was above goal (<100) in 76% of patients, but high density lipoprotein (mean 53 mg/dL) was at goal in 46%, and triglycerides (mean 138 mg/dL) were at goal in 85%. Diastolic pressure (mean 75 mm Hg) was at goal (<85) in 77% of patients, but systolic pressure (mean 143) was at goal (<130) in only 25% of patients. An average of only 53% of the patients had urine protein screening per 12 months, and use of aspirin was documented for only 39% of patients. CONCLUSIONS: Patients with type 2 diabetes in a typical internal medicine resident primary care clinic frequently do not achieve national standard of care goals. Since skills and attitudes developed in residency are likely to carry over into later practice, local diabetes educators may need to work with medical faculty to develop new interventions to improve postgraduate medical education in diabetes management.

    Title Description and Preliminary Evaluation of a Multiagent Intelligent Dosing System (maids) to Manage Combination Insulin-oral Agent Therapy in Type 2 Diabetes.
    Date February 2006
    Journal Diabetes Technology & Therapeutics
    Excerpt

    BACKGROUND: Computer decision support systems are potentially effective methods for adjusting insulin, but current models do not take into account simultaneous changes of more than one agent. We describe the development of the Multiagent Intelligent Dosing System (MAIDS, Dimensional Dosing Systems, Wexford, PA) for predicting glycemic outcome in response to concurrent dose adjustments in oral hypoglycemic agents and insulin. METHODS: Retrospective data from a patient cohort with type 2 diabetes who had simultaneous changes in insulin and metformin were analyzed. Glycemic markers (fasting glucose, random glucose, or hemoglobin A1c) expected at the visit subsequent to dose changes were calculated using two methods: the previously reported Intelligent Dosing System (IDStrade mark, Dimensional Dosing Systems), which accounts for changes in only one agent, and the MAIDS. Expected results from both systems were correlated with levels actually observed. RESULTS: We analyzed 32 patients with 40 paired visits. For fasting glucose (n = 8 paired visits), the correlation between expected and observed values was 0.07 when using the IDS but 0.78 when using the MAIDS. For random glucose (n = 16 paired visits) the correlation between expected and observed levels was 0.49 for the IDS but 0.79 for the MAIDS. With hemoglobin A1c as the marker (n = 16 paired visits), the correlation was 0.40 when using the IDS but 0.60 with the MAIDS. CONCLUSIONS: The MAIDS allows better prediction of glycemic outcome in circumstances where both insulin and an oral hypoglycemic drug are changed concurrently. Application of the MAIDS to other clinical scenarios, such as simultaneous adjustment of insulin and carbohydrate intake, requires further study.

    Title Use of Continuous Subcutaneous Insulin Infusion (insulin Pump) Therapy in the Hospital Setting: Proposed Guidelines and Outcome Measures.
    Date February 2006
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: Individuals whose diabetes is being treated in the outpatient setting via an insulin pump often wish to maintain this therapy during hospitalization. The authors propose guidelines for management of patients on insulin pumps who require a hospital admission. METHODS: A collaborative interinstitutional task force reviewed current available information regarding the use of insulin pumps in the hospital. RESULTS: There was little information in the medical literature on how to manage individuals on established insulin pump therapy during a hospital stay. The task force believed that a policy that promotes patient independence through continuation of insulin pump therapy while ensuring patient safety was possible. A set of contraindications for continued use of pump therapy in the hospital are proposed. A sample patient consent form and order set are presented. Finally, measures that can be used to assess effectiveness of an inpatient insulin pump policy are outlined. CONCLUSIONS: Patients on established insulin pump therapy do not necessarily have to discontinue treatment while hospitalized. However, clear policies and procedures should be established at the institutional level to guide continued use of the technology in the acute care setting.

    Title Limited Health Care Access Impairs Glycemic Control in Low Income Urban African Americans with Type 2 Diabetes.
    Date February 2006
    Journal Journal of Health Care for the Poor and Underserved
    Excerpt

    Limited access to health care is associated with adverse outcomes, but few studies have examined its effect on glycemic control in minority populations. Our observational cross-sectional study examined whether differences in health care access affected hemoglobin A1c (HbA1c) levels in 605 patients with diabetes (56% women; 89% African American; average age, 50 years; 95% with type 2 diabetes) initially treated at a municipal diabetes clinic. Patients who had difficulty obtaining care had higher A1c levels (9.4% vs. 8.7%; p=0.001), as did patients who used acute care facilities (9.5%; p<0.001) or who had no usual source of care (10.3%; p<0.001) compared with those who sought care at doctors' offices or clinics (8.6%). In adjusted analyses, HbA1c was higher in persons who gave a history of trouble obtaining medical care (0.57%; p=0.04), among persons who primarily used an acute care facility to receive their health care (0.49%; p=0.047), and in patients who reported not having a usual source of care (1.08%; p=0.009). Policy decisions for improving diabetes outcomes should target barriers to health care access and focus on developing programs to help high-risk populations maintain a regular place of health care.

    Title An Endocrinologist-supported Intervention Aimed at Providers Improves Diabetes Management in a Primary Care Site: Improving Primary Care of African Americans with Diabetes (ipcaad) 7.
    Date December 2005
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS: A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both. RESULTS: Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001). CONCLUSIONS: Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings.

    Title Response to Bequette and Desemone Regarding the Intelligent Dosing System.
    Date November 2005
    Journal Diabetes Technology & Therapeutics
    Title Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting.
    Date October 2005
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: The purpose of this study was to determine whether "clinical inertia"-inadequate intensification of therapy by the provider-could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. METHODS: In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. RESULTS: Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). CONCLUSIONS: Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.

    Title Evolving Demographics and Disparities in an Urban Diabetes Clinic: Implications for Diabetes Education and Treatment.
    Date August 2005
    Journal Ethnicity & Disease
    Excerpt

    OBJECTIVES: To compare demographics and disease characteristics in a multiethnic diabetes clinic population to identify changes over time. DESIGN: Analysis and comparison of demographics and disease characteristics of diabetes patients, recorded electronically at intake over 10 years. SETTING: An urban outpatient diabetes clinic. PATIENTS: A total of 8,551 African-American (88%), White (7%), or Hispanic (3%) patients (average age, 52 years; mean diabetes duration, 5.1 years; 59% women). MAIN OUTCOME MEASURES: Proportion of patients by ethnic group, age, diabetes duration, initial hemoglobin A1c, and body mass index. RESULTS: Between 1992 and 2001, the percentage of African-American patients was relatively unchanged (from 87.6% to 87.2%; P=.2), White patients decreased (from 9% to 5%; P=.0006), and Hispanic patients increased (from 1.3% to 5.5%; P<.0001). Among African-American patients, average age decreased from 52 to 50 years (P=.015), diabetes duration decreased from 5.6 years to 4.3 years (P=.0003), initial hemoglobin A1c decreased from 9.3% to 8.8% (P<.0001), and body mass index increased from 31 kg/m2 to 32.1 kg/m2 (P=.0001). Compared with African-American and White patients, Hispanic patients were younger (P<.0001) and had a lower body mass index (P<.0001) but had hemoglobin A1c comparable to that of African-American patients (9.3% vs 9.1%; P=.45) and higher than that of White patients (9.3% vs 8.7%; P=.0022). CONCLUSIONS: The demographic and disease profiles of patients in this urban diabetes clinic have shifted, and disparities in glycemic control and obesity exist. Modifications in treatment and education approaches may be necessary to compensate for a changing patient population.

    Title Barriers to Diabetes Education in Urban Patients: Perceptions, Patterns, and Associated Factors.
    Date July 2005
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: This study explored patients' perceptions of barriers to diabetes education among a mostly African American population of adults with diabetes. METHODS: A survey was conducted among 605 new patients attending an urban outpatient diabetes clinic. The questionnaire gathered information on issues patients believed would adversely affect their ability to learn about diabetes. The type and frequency of education barriers were evaluated, and variables associated with reporting an obstacle were analyzed. RESULTS: Average patient age was 50 years, diabetes duration was 5.6 years, body mass index was 32 kg/m2, and hemoglobin A1C was 9.1%. The majority (56%) were women, 89% were African American, and 95% had type 2 diabetes. Most respondents (96%) had received some prior instruction in diabetes care; however, 53% anticipated future difficulties learning about diabetes. The most commonly cited concerns were poor vision (74%) and reading problems (29%). Patients with a perceived barrier to diabetes education were older (P < .001) than were persons without a barrier, and they differed in both employment and educational status (both P < .001). In adjusted analyses, older age, male gender, being disabled, and having an elementary education or less were associated with a significantly increased likelihood of having a barrier to diabetes education, whereas having a college education decreased the odds. Higher hemoglobin A1C levels also tended to be associated with a greater chance of reporting an education barrier (P = .05). CONCLUSIONS: A substantial number of persons anticipated a barrier to diabetes education. Interventions at multiple levels that address the demographic and socioeconomic obstacles to diabetes education are needed to ensure successful self-management training.

    Title Management of Insulin Therapy in Urban Diabetes Patients is Facilitated by Use of an Intelligent Dosing System.
    Date June 2005
    Journal Diabetes Technology & Therapeutics
    Excerpt

    The Intelligent Dosing System (IDS, Dimensional Dosing Systems, Inc., Wexford, PA) is a software suite that incorporates patient-specific, dose-response data in a mathematical model, and then calculates the new dose of agent needed to achieve the next desired therapeutic goal. We evaluated use of the IDS for titrating insulin therapy. The IDS was placed on handheld platforms and provided to practitioners to use in adjusting total daily insulin dose. Fasting glucose, random glucose, and hemoglobin A1c were used as markers against which insulin could be adjusted. Values of markers expected at the next follow-up visit, as predicted by the model, were compared with levels actually observed. For 264 patients, 334 paired visits were analyzed. Average age was 54 years, diabetes' duration was 10 years, and body mass index was 33.2 kg/m(2); 57% were female, 88% were African American, and 92% had type 2 diabetes. The correlation between IDS suggested and actual prescribed total daily dose was high (r = 0.99), suggesting good acceptability of the IDS by practitioners. Significant decreases in fasting glucose, random glucose, and hemoglobin A1c levels were seen (all P < 0.0001). No significant difference between average expected and observed follow-up fasting glucose values was found (145 vs. 149 mg/dL, P = 0.42), and correlation was high (r = 0.79). Mean observed random glucose value at follow-up was comparable to the IDS predicted level (167 vs. 168 mg/dL, P = 0.97), and correlation was high (r = 0.73). Observed follow-up hemoglobin A1c was higher than the value expected (7.9% vs. 7.4%, P < 0.0055), but correlation was good (r = 0.70). These analyses suggest the IDS is a useful adjunct for decisions regarding insulin therapy even when using a variety of markers of glucose control, and can be used by practitioners to assist in attainment of glycemic goals.

    Title Patient Adherence Improves Glycemic Control.
    Date May 2005
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: The purpose of this study was to assess the influence of appointment keeping and medication adherence on HbA1c. METHODS: A retrospective evaluation was performed in 1560 patients with type 2 diabetes who presented for a new visit to the Grady Diabetes Clinic between 1991 and 2001 and returned for a follow-up visit and HbA1c after 1 year of care. Appointment keeping was assessed by the number of scheduled intervening visits that were kept, and medication adherence was assessed by the percentage of visits in which self-reported diabetes medication use was as recommended at the preceding visit. RESULTS: The patients had an average age of 55 years, body mass index (BMI) of 32 kg/m2, diabetes duration of 4.6 years, and baseline HbA1c of 9.1%. Ninety percent were African American, and 63% were female. Those who kept more intervening appointments had lower HbA1c levels after 12 months of care (7.6% with 6-7 intervening visits vs 9.7% with 0 intervening visits). Better medication adherence was also associated with lower HbA1c levels after 12 months of care (7.8% with 76%-100% adherence). After adjusting for age, gender, race, BMI, diabetes duration, and diabetes therapy in multivariate linear regression analysis, the benefits of appointment keeping and medication adherence remained significant and contributed independently; the HbA1c was 0.12% lower for every additional intervening appointment that was kept (P = .0001) and 0.34% lower for each quartile of better medication adherence (P = .0009). CONCLUSION: Keeping more appointments and taking diabetes medications as directed were associated with substantial improvements in HbA1c. Efforts to enhance glycemic outcomes should include emphasis on these simple but critically important aspects of patient adherence.

    Title The Intelligent Dosing System: Application for Insulin Therapy and Diabetes Management.
    Date May 2005
    Journal Diabetes Technology & Therapeutics
    Excerpt

    Diabetes mellitus is an increasing public health problem. Insulin is an essential tool in the management of hyperglycemia, but methods of dose adjustment are purely empirical. The Intelligent Dosing System (IDS, Dimensional Dosing Systems, Inc., Wexford, PA) is a software suite that incorporates patient-specific, dose-response data in a mathematical model and then calculates the new dose of the medication needed to achieve the next desired therapeutic goal. We discuss the application of the IDS in insulin management. The IDS concept and the initial modeling used to construct an insulin doser are reviewed first. Additional data are then provided on the use of the IDS for titrating insulin therapy in a clinical setting. Finally, recent modifications in the IDS software and future applications of this technology for insulin dosing and diabetes management are discussed.

    Title Exercise Preferences and Barriers in Urban African Americans with Type 2 Diabetes.
    Date November 2004
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: The purpose of this study was to determine physical activity preferences and barriers to exercise in an urban diabetes clinic population. METHODS: A survey was conducted of all patients attending the clinic for the first time. Evaluation measures were type and frequency of favorite leisure-time physical activity, prevalence and types of reported barriers to exercise, and analysis of patient characteristics associated with reporting an obstacle to exercise. RESULTS: For 605 patients (44% male, 89% African American, mean age = 50 years, mean duration of diabetes = 5.6 years), the average frequency of leisure activity was 3.5 days per week (mean time = 45 minutes per session). Walking outdoors was preferred, but 52% reported an exercise barrier (predominantly pain). Patients who cited an impediment to physical activity exercised fewer days per week and less time each session compared with persons without a barrier. Increasing age, body mass index, college education, and being a smoker increased the odds of reporting a barrier; being male decreased the chances. Men reported more leisure-time physical activity than women. Exercise preferences and types of barriers changed with age. CONCLUSIONS: Recognition of patient exercise preferences and barriers should help in developing exercise strategies for improving glycemic control.

    Title Utility of Casual Postprandial Glucose Levels in Type 2 Diabetes Management.
    Date September 2004
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: Because readily available glycemic indicators are needed to guide clinical decision-making for intensification of diabetes therapy, our goals were to define the relationship between casual postprandial plasma glucose (cPPG) levels and HbA(1c) in patients with type 2 diabetes and to determine the predictive characteristics of a convenient glucose cutoff. RESEARCH DESIGN AND METHODS: We examined the relationship between cPPG levels (1-4 h post meal) and HbA(1c) levels in 1,827 unique patients who had both determinations during a single office visit. RESULTS: The population studied was predominantly African American and middle-aged, with average cPPG of 201 mg/dl and HbA(1c) of 8.4%. The prevalence of HbA(1c) > or = 7.0% was 67% and HbA(1c) >6.5% was 77%. Overall, cPPG and HbA(1c) were linearly correlated (r = 0.63, P < 0.001). The correlation between cPPG and HbA(1c) was strongest in patients treated with diet alone (n = 348, r = 0.75, P < 0.001) and weaker but still highly significant for patients treated with oral agents (n = 610, r = 0.64, P < 0.001) or insulin (n = 869, r = 0.56, P < 0.001). A cutoff cPPG >150 mg/dl predicted an HbA(1c) level > or = 7.0% in the whole group, with a sensitivity of 78%, a specificity of 62%, and an 80% positive predictive value. The same cPPG cutoff of 150 mg/dl predicted an HbA(1c) level >6.5%, with a sensitivity of 74%, a specificity of 66%, and an 88% positive predictive value. CONCLUSIONS: When rapid-turnaround HbA(1c) determinations are not available, a single cPPG level >150 mg/dl may be used during a clinic visit to identify most inadequately controlled patients and allow timely intensification of therapy.

    Title Little Time for Diabetes Management in the Primary Care Setting.
    Date April 2004
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: This study was conducted to determine how time is allocated to diabetes care. METHODS: Patients with type 2 diabetes who were receiving care from the internal medicine residents were shadowed by research nurses to observe the process of management. The amount of time spent with patients and the care provided were observed and documented. RESULTS: The total time patients spent in the clinic averaged 2 hours and 26 minutes: 1 to 9 minutes waiting, 25 minutes with the resident, and 12 minutes with medical assistants and nurses. The residents spent an average of only 5 minutes on diabetes. Glucose monitoring was addressed in 70% of visits; a history of hypoglycemia was sought in only 30%. Blood pressure values were mentioned in 75% of visits; hemoglobin A1c (A1C) values were addressed in only 40%. The need for proper foot care was discussed in 55% of visits; feet were examined in only 40%. Although 65% of patients had capillary glucose levels greater than 150 mg/dL during the visit and their A1C averaged 8.9%, therapy was intensified for only 15% of patients. CONCLUSIONS: During a routine office visit in a resident-staffed general medicine clinic, little time is devoted to diabetes management. Given the time pressures on the primary care practitioner and the need for better diabetes care, it is essential to teach an efficient but systematic approach to diabetes care.

    Title Inpatient to Outpatient Transfer of Care in Urban Patients with Diabetes: Patterns and Determinants of Immediate Postdischarge Follow-up.
    Date March 2004
    Journal Archives of Internal Medicine
    Excerpt

    BACKGROUND: A key opportunity for continuing diabetes care is to assure outpatient follow-up after hospitalization. To delineate patterns and factors associated with having an ambulatory care visit, we examined immediate postdischarge follow-up among a cohort of urban, hospitalized patients with diabetes mellitus. METHODS: Retrospective study of 658 inpatients of a municipal hospital. Primary data sources were inpatient surveys and electronic records. RESULTS: Patients were stratified into outpatient follow-up (69%), acute care follow-up (15%), and those with no follow-up (16%); differences between groups were detected for age (P =.02), percentage discharged with insulin (P =.03), and percentage receiving a full discount for care (P<.001). Among patients with a postdischarge visit, 43% were seen in our specialty diabetes clinic, and 26% in a primary care site. Adjusted analyses showed any follow-up visit significantly decreased with having to pay for care. The odds of coming to the Diabetes Clinic increased if patients were discharged with insulin, had new-onset diabetes, or had a direct referral. CONCLUSIONS: In this patient cohort, most individuals accomplished a postdischarge visit, but a substantial percentage had an acute care visit or no documented follow-up. New efforts need to be devised to track patients after discharge to assure care is achieved, especially in this patient population particularly vulnerable to diabetes.

    Title Hypercalcemia in Hyperthyroidism: Patterns of Serum Calcium, Parathyroid Hormone, and 1,25-dihydroxyvitamin D3 Levels During Management of Thyrotoxicosis.
    Date February 2004
    Journal Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists
    Excerpt

    OBJECTIVE: To present two cases of hypercalcemia associated with thyrotoxicosis and to describe serial biochemical findings during the course of treatment of hyperthyroidism. METHODS: We report two cases, illustrate the changes in serum calcium, parathyroid hormone, and 1,25-dihydroxyvitamin D3 levels during management of thyrotoxicosis, and compare our findings with those in previous studies. RESULTS: Hypercalcemia attributable to thyrotoxicosis is well documented, but the mechanism for the hypercalcemia is incompletely understood. Our first patient had a complicated medical history and several potential causes of hypercalcemia, including recurrent hyperparathyroidism, metastatic breast cancer, and relapse of previously treated thyrotoxicosis. A suppressed parathyroid hormone level and negative bone and computed tomographic scans excluded the first two factors. After thyroid ablation with 131I, the serum calcium and thyroxine levels decreased, and the parathyroid hormone and 1,25-dihydroxyvitamin D3 levels normalized. Our second patient, who was referred to our institution with a preliminary diagnosis of hypercalcemia associated with malignant disease and who had no symptoms of hyperthyroidism, was found to have a high free thyroxine level, diffuse enlargement of the thyroid, and high uptake (58%) of 123I on a thyroid scan. After thyroid ablation, the serum calcium, 1,25-dihydroxyvitamin D3, and intact parathyroid hormone levels normalized, and the free thyroxine level declined. The probable pathogenesis of hypercalcemia in thyrotoxicosis is reviewed with respect to thyroid hormone and its effect on bone turnover. CONCLUSION: Physicians should consider thyrotoxicosis in the differential diagnosis of hypercalcemia.

    Title A Simple Meal Plan Emphasizing Healthy Food Choices is As Effective As an Exchange-based Meal Plan for Urban African Americans with Type 2 Diabetes.
    Date January 2004
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: To compare a simple meal plan emphasizing healthy food choices with a traditional exchange-based meal plan in reducing HbA(1c) levels in urban African Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 648 patients with type 2 diabetes were randomized to receive instruction in either a healthy food choices meal plan (HFC) or an exchange-based meal plan (EXCH) to compare the impact on glycemic control, weight loss, serum lipids, and blood pressure at 6 months of follow-up. Dietary practices were assessed with food frequency questionnaires. RESULTS: At presentation, the HFC and EXCH groups were comparable in age (52 years), sex (65% women), weight (94 kg), BMI (33.5), duration of diabetes (4.8 years), fasting plasma glucose (10.5 mmol/l), and HbA(1c) (9.4%). Improvements in glycemic control over 6 months were significant (P < 0.0001) but similar in both groups: HbA(1c) decreased from 9.7 to 7.8% with the HFC and from 9.6 to 7.7% with the EXCH. Improvements in HDL cholesterol and triglycerides were comparable in both groups, whereas other lipids and blood pressure were not altered. The HFC and EXCH groups exhibited similar improvement in dietary practices with respect to intake of fats and sugar sweetened foods. Among obese patients, average weight change, the percentage of patients losing weight, and the distribution of weight lost were comparable with the two approaches. CONCLUSIONS: Medical nutrition therapy is effective in urban African Americans with type 2 diabetes. Either a meal plan emphasizing guidelines for healthy food choices or a low literacy exchange method is equally effective as a meal planning approach. Because the HFC meal plan may be easier to teach and easier for patients to understand, it may be preferable for low-literacy patient populations.

    Title Rapid A1c Availability Improves Clinical Decision-making in an Urban Primary Care Clinic.
    Date October 2003
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: Failure to meet goals for glycemic control in primary care settings may be due in part to lack of information critical to guide intensification of therapy. Our objective is to determine whether rapid-turnaround A1c availability would improve intensification of diabetes therapy and reduce A1c levels in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: In this prospective controlled trial, A1c was determined on capillary glucose samples and made available to providers, either during ("rapid") or after ("routine") the patient visit. Frequency of intensification of pharmacological diabetes therapy in inadequately controlled patients and A1c levels were assessed at baseline and after follow-up. RESULTS: We recruited 597 subjects. Patients were 79% female and 96% African American, with average age of 61 years, duration of diabetes 10 years, BMI 33 kg/m(2), and A1c 8.5%. The rapid and routine groups had similar clinical demographics. Rapid A1c availability resulted in more frequent intensification of therapy when A1c was >/=7.0% at the baseline visit (51 vs. 32% of patients, P = 0.01), particularly when A1c was >8.0% and/or random glucose was in the 8.4-14.4 mmol/l range (151-250 mg/dl). In 275 patients with two follow-up visits, A1c fell significantly in the rapid group (from 8.4 to 8.1%, P = 0.04) but not in the routine group (from 8.1 to 8.0%, P = 0.31). CONCLUSIONS: Availability of rapid A1c measurements increased the frequency of intensification of therapy and lowered A1c levels in patients with type 2 diabetes in an urban neighborhood health center.

    Title Chromium As Adjunctive Treatment for Type 2 Diabetes.
    Date July 2003
    Journal The Annals of Pharmacotherapy
    Excerpt

    OBJECTIVE: To review the chemistry, pharmacology, efficacy, and safety of trivalent chromium in the treatment of type 2 diabetes and hyperlipidemia. DATA SOURCES: The English literature was searched from 1966 through May 2002 using MEDLINE, International Pharmaceutical Abstracts, and EMBASE. The key words included chromium, glucose, lipids, and diabetes. Pertinent references from review articles and studies were used as additional sources. DATA SYNTHESIS: Trivalent chromium is an essential nutrient and has a key role in lipid and glucose metabolism. Supplementation with chromium does not appear to reduce glucose levels in euglycemia. It may, however, have some efficacy in reducing glucose levels in hyperglycemia. The effects of chromium on lipid levels are variable. Chromium in doses <1000 microg/d appears to be safe for short-term administration. Kidney function and dermatologic changes need to be monitored. CONCLUSIONS: Chromium appears to be a safe supplement and may have a role as adjunctive therapy for treatment of type 2 diabetes. Additional large-scale, long-term, randomized, double-blind studies examining the effect of various doses and forms of chromium are needed.

    Title Association of Younger Age with Poor Glycemic Control and Obesity in Urban African Americans with Type 2 Diabetes.
    Date January 2003
    Journal Archives of Internal Medicine
    Excerpt

    BACKGROUND: Type 2 diabetes mellitus is highly prevalent in minority populations in the United States. We studied the relationship of age to glycemic control in a predominantly urban African American population with type 2 diabetes. METHODS: We selected all patients with type 2 diabetes who were enrolled in the Grady Diabetes Clinic, Atlanta, Ga, between April 1, 1991, and December 31, 1998, and had a hemoglobin A(1c) (HbA(1c)) level measured at their initial visit and at follow-up 5 to 12 months later (n = 2539). Patients were divided into 4 age categories: less than 30 years, 30 to 49 years, 50 to 69 years, and more than 69 years old. We also studied the relationship of age to HbA(1c) level in a primary care clinic. RESULTS: At baseline, average HbA(1c) levels were 9.9%, 9.5%, 9.2%, and 8.8% in the 4 groups ranked in increasing age, respectively (P<.001), and body mass indexes (calculated as weight in kilograms divided by the square of height in meters) were 37.8, 33.9, 31.6, and 29.2, respectively (P<.001). On follow-up, HbA( 1c) level improved in all groups (P<.001), but there was still a trend for younger patients to have higher levels of HbA(1c). There was little change in body mass index with time. Younger age, longer diabetes duration, higher body mass index, less frequent interval visits, and treatment with oral agents or insulin were associated with a higher HbA(1c) level at follow-up. Our findings in a primary care clinic showed also that HbA( 1c) level and body mass index were negatively correlated with age (P<.001). CONCLUSION: Our data show a high prevalence of obesity and poor glycemic control in young adult urban African Americans with diabetes.

    Title The Improving Primary Care of African Americans with Diabetes (ipcaad) Project: Rationale and Design.
    Date December 2002
    Journal Controlled Clinical Trials
    Excerpt

    African Americans have an increased burden of both diabetes and diabetes complications. Since many patients have high glucose levels novel interventions are needed, especially for urban patients with limited resources. In the Grady Diabetes Clinic in Atlanta, a stepped care strategy improves metabolic control. However, most diabetes patients do not receive specialized care. We will attempt to translate diabetes clinic approaches to the primary care setting by implementing a novel partnership between specialists and generalists. We hypothesize that endocrinologist-supported strategies aimed at providers will result in effective diabetes management in primary care sites, and the Improving Primary Care of African Americans with Diabetes project will test this hypothesis in a major randomized, controlled trial involving over 2000 patients. Physicians in Grady Medical Clinic units will receive (1) usual care, (2) computerized reminders that recommend individualized changes in therapy and/or (3) directed discussion by endocrinologists providing feedback on performance. We will measure outcomes related to both microvascular disease (HbA1c, which reflects average glucose levels over an approximately 2-month period) and macrovascular disease (blood pressure and lipids) and assess provider performance as well. We will compare two readily generalizable program interventions that should delineate approaches effective in a primary care setting as needed to improve care and prevent complications in urban African Americans with type 2 diabetes.

    Title Physician Assistant Students and Diabetes: Evaluation of Attitudes and Beliefs.
    Date May 2002
    Journal The Diabetes Educator
    Excerpt

    PURPOSE: Physician assistants are assuming a greater role in patient care in the US health system. The objective of this study was to examine attitudes and beliefs about diabetes among physician assistant trainees. METHODS: A survey of 3 currently enrolled classes of physician assistant students was conducted using the Diabetes Attitude Survey (DAS, version 3). An additional question was presented to gather information about the level of hyperglycemia at which students would intensify diabetes therapy. RESULTS: On average, students scored high on all subscales, indicating general agreement with the attitudes examined by the DAS. For 3 subscales (seriousness of type 2 diabetes, value of tight glucose control, and patient autonomy), significant differences were seen across year of training. When asked about the level of glucose control at which they would advance therapy, a wide range of responses occurred, with some being out of target. CONCLUSIONS: Physician assistant students had favorable attitudes regarding type 2 diabetes. However, deficits appear to exist in understanding when to advance therapy. More studies on physician assistant students' knowledge of diabetes standards of care are required.

    Title Electronic Journals: Are They a Paradigm Shift?
    Date March 2002
    Journal Online Journal of Issues in Nursing
    Excerpt

    Ejournals are becoming an accepted and necessary means of meeting the demands for the dissemination of knowledge. This introductory article discusses the recent "explosion" of ejournals and provides an explanation of what is meant by an "ejournal." Ejournals are explored within the traditional context of scholarship and a discussion of the "serials crisis" that promoted the inception of ejournals is presented. After laying the groundwork for discussing scholarship in this new age of dissemination of scholarly information, the article discusses whether this digital form of publication can be called a "paradigm shift" in Kuhn's (1970) traditional sense of the word.

    Title The Impact of Outpatient Diabetes Management on Serum Lipids in Urban African-americans with Type 2 Diabetes.
    Date March 2002
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: Treating dyslipidemia in diabetic patients is essential, particularly among minority populations with increased risk of complications. Because little is known about the impact of outpatient diabetes management on lipid outcomes, we examined changes in lipid profiles in urban African-Americans who attended a structured diabetes care program. RESEARCH DESIGN AND METHODS: A retrospective analysis of initial and 1-year follow-up lipid values was conducted among patients selected from a computerized registry of an urban outpatient diabetes clinic. The independent effects of lipid-specific medications, glycemic control, and weight loss on serum total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride levels were evaluated by analysis of covariance and multiple linear regression. RESULTS: In 345 patients (91% African-American and 95% with type 2 diabetes), HbA(1c) decreased from 9.3% at the initial visit to 8.2% at 1 year (P < 0.001); total and LDL cholesterol and triglyceride levels were significantly lower, and HDL cholesterol was higher. After stratifying based on use of lipid-specific therapy, different outcomes were observed. In 243 patients not taking dyslipidemia medications, average total cholesterol, LDL cholesterol, and triglyceride concentrations at 1 year were similar to initial values, whereas in 102 patients receiving pharmacotherapy, these lipid levels were all lower at 1 year relative to baseline (P < 0.001). Mean HDL cholesterol increased regardless of lipid treatment status (P < 0.001). After adjusting for other variables, changes in LDL cholesterol concentration were associated only with use of lipid-specific agents (P = 0.003), whereas improved HbA(1c) and weight loss had no independent effect. Lipid therapy, improved glycemic control, and weight loss were not independently related to changes in HDL cholesterol and therefore could not account for the positive changes observed. Use of lipid-directed medications, improvement in glycemic control, and weight loss all resulted in significant declines in triglyceride levels but only improved HbA(1c) and weight loss had an independent effect. CONCLUSIONS: Among urban African-Americans, diabetes management led to favorable changes in HDL cholesterol and triglyceride levels, but improved glycemic control and weight loss had no independent effect on LDL cholesterol concentration. Initiation of pharmacologic therapy to treat high LDL cholesterol levels should be considered early in the course of diabetes management to reach recommended targets and reduce the risk of cardiovascular complications in this patient population.

    Title Clinical Inertia.
    Date December 2001
    Journal Annals of Internal Medicine
    Excerpt

    Medicine has traditionally focused on relieving patient symptoms. However, in developed countries, maintaining good health increasingly involves management of such problems as hypertension, dyslipidemia, and diabetes, which often have no symptoms. Moreover, abnormal blood pressure, lipid, and glucose values are generally sufficient to warrant treatment without further diagnostic maneuvers. Limitations in managing such problems are often due to clinical inertia-failure of health care providers to initiate or intensify therapy when indicated. Clinical inertia is due to at least three problems: overestimation of care provided; use of "soft" reasons to avoid intensification of therapy; and lack of education, training, and practice organization aimed at achieving therapeutic goals. Strategies to overcome clinical inertia must focus on medical students, residents, and practicing physicians. Revised education programs should lead to assimilation of three concepts: the benefits of treating to therapeutic targets, the practical complexity of treating to target for different disorders, and the need to structure routine practice to facilitate effective management of disorders for which resolution of patient symptoms is not sufficient to guide care. Physicians will need to build into their practice a system of reminders and performance feedback to ensure necessary care.

    Title The Influence of "host Release Factor" on Carbon Release by Zooxanthellae Isolated from Fed and Starved Aiptasia Pallida (verrill).
    Date October 2001
    Journal Comparative Biochemistry and Physiology. Part A, Molecular & Integrative Physiology
    Excerpt

    Symbiotic dinoflagellates (zooxanthellae) typically respond to extracts of host tissue with enhanced release of short-term photosynthetic products. We examined this "host release factor" (HRF) response using freshly isolated zooxanthellae of differing nutritional status. The nutritional status was manipulated by either feeding or starving the sea anemone Aiptasia pallida (Verrill). The release of fixed carbon from isolated zooxanthellae was measured using 14C in 30 min experiments. Zooxanthellae in filtered seawater alone released approximately 5% of photosynthate irrespective of host feeding history. When we used a 10-kDa ultrafiltrate of A. pallida host tissue as a source of HRF, approximately 14% of photosynthate was released to the medium. This increased to over 25% for zooxanthellae from anemones starved for 29 days or more. The cell-specific photosynthetic rate declined with starvation in these filtrate experiments, but the decline was offset by the increased percentage release. Indeed, the total amount of released photosynthate remained unchanged, or even increased, as zooxanthellae became more nutrient deficient. Similar trends were also observed when zooxanthellae from A. pallida were incubated in a 3-kDa ultrafiltrate of the coral Montastraea annularis, suggesting that HRF in the different filtrates operated in a similar manner. Our results support the suggestion that HRF diverts surplus carbon away from storage compounds to translocated compounds such as glycerol.

    Title Hypoglycemia in Patients with Type 2 Diabetes Mellitus.
    Date July 2001
    Journal Archives of Internal Medicine
    Excerpt

    BACKGROUND: Although hypoglycemia is the most common complication of intensive diabetes therapy, there is little information about risk factors for hypoglycemia in patients with type 2 diabetes mellitus. OBJECTIVE: To determine the prevalence and predisposing factors for hypoglycemia in patients with type 2 diabetes. METHODS: Retrospective, cross-sectional analysis set in an outpatient specialty diabetes clinic. We included those patients who had baseline and follow-up visits from April 1 through October 31, 1999. Hypoglycemia was defined as typical symptoms relieved by eating, and/or blood glucose level of less than 60 mg/dL (<3.3 mmol/L). Univariate and multivariate logistic regression were used to determine the contributions to hypoglycemia of age, sex, diabetes duration, body mass index (calculated as weight in kilograms divided by the square of height in meters), fasting plasma glucose level, glycosylated hemoglobin (HbA(1c)) level, type of therapy, and previous episodes at the follow-up visit. RESULTS: We studied 1055 patients. Prevalence of hypoglycemic symptoms was 12% (9/76) for patients treated with diet alone, 16% (56/346) for those using oral agents alone, and 30% (193/633) for those using any insulin (P<.001). Severe hypoglycemia occurred in only 5 patients (0.5%), all using insulin. Multiple logistic regression analysis demonstrated that insulin therapy, lower HbA(1c) level at follow-up, younger age, and report of hypoglycemia at the baseline visit were independently associated with increased prevalence of hypoglycemia. There were no significant predictors of severe hypoglycemia. CONCLUSIONS: Mild hypoglycemia is common in patients with type 2 diabetes undergoing aggressive diabetes management, but severe hypoglycemia is rare. Concerns about hypoglycemia should not deter efforts to achieve tight glycemic control in most patients with type 2 diabetes.

    Title Comorbidity and Glycemic Control in Patients with Type 2 Diabetes.
    Date June 2001
    Journal Archives of Internal Medicine
    Excerpt

    BACKGROUND: It is commonly believed that good glycemic control is hard to achieve in patients with diabetes mellitus and concurrent chronic illnesses. OBJECTIVE: To determine the impact of comorbidity on glycemic control at presentation and subsequent follow-up in patients with type 2 diabetes. METHODS: We studied 654 consecutive patients who presented to a diabetes clinic in 1997. Comorbidity was rated using the Chronic Disease Score (CDS) index, which is a validated, weighted score that takes into account the patient's age, sex, and classes of medications. Univariate and multivariate linear regressions were used to determine the contribution of age, body mass index (calculated as weight in kilograms divided by the square of height in meters), diabetes duration, type of therapy, and CDS to initial hemoglobin A(1c) (HbA(1c)) level. A similar analysis was performed for the 169 patients with follow-up HbA(1c) levels 6 months after presentation. RESULTS: Patients were 90% African American, and 66% female, with average age of 53 years. Average diabetes duration was 5 years; body mass index, 33; HbA(1c) level, 8.8%; and CDS, 1121 (range, 232-7953). At presentation, patients with higher CDSs tended to be older and to have a lower HbA(1c) level, but multivariate linear regression showed that receiving pharmacological therapy, younger age, and having a lower C-peptide level were the only significant contributors to HbA(1c) level. In the 169 follow-up patients, presenting characteristics were not significantly different from those of the full cohort: average initial HbA(1c) level was 8.8%; CDS, 1073. Their HbA(1c) level at 6 months averaged 7.5% and the CDS had no significant impact on their follow-up HbA(1c) level. CONCLUSION: Comorbidity does not appear to limit achievement of good glycemic control in patients with type 2 diabetes.

    Title The Potentially Poor Response to Outpatient Diabetes Care in Urban African-americans.
    Date March 2001
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: HbA1c levels can be reduced in populations of diabetic patients, but some individuals may exhibit little improvement. To search for reasons underlying differences in HbA1c outcome, we analyzed patients managed in an outpatient diabetes clinic. RESEARCH DESIGN AND METHODS: African-Americans with type 2 diabetes were categorized as responders, intermediate responders or poor responders according to their HbA1c level after 1 year of care. Logistical regression was used to determine baseline characteristics that distinguished poor responders from responders. Therapeutic strategies were examined for each of the response categories. RESULTS: The 447 patients had a mean age and disease duration of 58 and 5 years, respectively, and BMI of 32 kg/m2. Overall, the mean HbA1c level fell from 9.6 to 8.1% after 12 months. Mean HbA1c levels improved from 8.8 to 6.2% in responders, and from 9.5 to 7.9% in intermediate responders. In poor responders, the average HbA1c level was 10.8% on presentation and 10.9% at 1 year. The odds of being a poor responder were significantly increased with longer disease duration, higher initial HbA1c level, and greater BMI. Although doses of oral agents and insulin were significantly higher among poor responders at most visits, the acceleration of insulin therapy did not occur until late in the follow-up period. CONCLUSIONS: Clinical diabetes programs need to devise methods to identify patients who are at risk for persistent hyperglycemia. Whereas patient characteristics explain some heterogeneity of HbA1c outcome (and may aid in earlier identification of patients who potentially may not respond to conventional treatment), insufficient intensification of therapy may also be a component underlying the failure to achieve glycemic goals.

    Title The Pattern of Dyslipidemia Among Urban African-americans with Type 2 Diabetes.
    Date October 2000
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: To analyze lipid profiles from a large sample of African-American patients with type 2 diabetes who receive care at an urban outpatient diabetes clinic. RESEARCH DESIGN AND METHODS: Fasting serum lipid profiles of 4,014 African-Americans and 328 Caucasians with type 2 diabetes were retrieved from a computerized registry. American Diabetes Association criteria were applied to classify LDL cholesterol, HDL cholesterol, and triglyceride (TG) levels into risk categories. The proportion of patients who had none, one, two, and three lipoprotein concentrations outside of recommended clinical targets was examined. Multiple logistical regression analyses were performed to determine the influence of sex and race on the probability of having a lipid level outside of the recommended target. RESULTS: The percentages of African-Americans with high-, borderline-, and low-risk LDL cholesterol concentrations were 58, 26, and 16%, respectively, and the percentages for Caucasians were 54, 29, and 16%, respectively (P = 0.51). For HDL cholesterol, 41, 33, and 26% of African-Americans were in the high-, borderline-, and low-risk categories, respectively, compared with 73, 18, and 9% of Caucasians, respectively (P < 0.0001). Nearly 81% of African-Americans had TG concentrations that were in the low-risk category compared with only 50% of Caucasians. More women than men had high-risk LDL and HDL cholesterol profiles. The most common pattern of dyslipidemia was an LDL cholesterol level above target combined with an HDL cholesterol level below target, which was detected in nearly 50% of African-Americans and 42% of Caucasians. African-Americans had lower odds of having an HDL cholesterol or TG level outside of target. African-American women, compared to men, had greater probabilities of having abnormal levels of LDL and HDL, but a lower likelihood of having a TG level above goal. CONCLUSIONS: In a large sample of urban type 2 diabetic patients receiving care at a diabetes treatment program, race and sex differences in serum lipid profiles were present. Because hypertriglyceridemia was rare among African-American subjects, interventions will need to focus primarily on improving their LDL and HDL cholesterol levels. Further studies are required regarding how to best adapt these observed differences into more effective strategies to optimize lipid levels for this population of diabetic patients and to determine whether similar patterns of dyslipidemia occur in other clinical settings.

    Title Diabetes in Urban African-americans. Xix. Prediction of the Need for Pharmacological Therapy.
    Date September 2000
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: To develop a prediction rule that will identify patients who will require pharmacological therapy within 6 months of first presentation to a diabetes clinic. RESEARCH DESIGN AND METHODS: Among the patients who came to the Grady Diabetes Clinic between 1991 and 1997, we randomized 557 frequent attenders to a development group and 520 frequent attenders to a validation group. Using multiple logistical regression, we derived a prediction rule in the development group to project whether patients would require pharmacological intervention to achieve HbA1c levels <7% after 6 months. The utility of the prediction rule was then confirmed in the validation group and tested prospectively on an additional group of 93 patients who presented from 1997 to 1998. Performance of the prediction rule was assessed using receiver operating characteristic (ROC) curves. RESULTS: The rule (-4.469 + 1.932 x sulfonylurea Rx + 1.334 x insulin Rx + 0.196 x duration + 0.468 x fasting glucose, where "Rx" indicates a prescription) predicted the need for pharmacological intervention in the development group (P < 0.0001). Use of insulin or sulfonylurea therapy at presentation, duration of diabetes, and fasting glucose levels were significant predictors of the future need for pharmacological management. The prediction rule also performed well in the validation group (positive predictive value 90%, correlation between predicted and observed need for medical management 0.99). ROC curves confirmed the value of the prediction rule (area under the curves was 0.91 for the development group, 0.85 for the validation group, and 0.81 for the prospective group). CONCLUSIONS: Early identification of individuals who will require pharmacological intervention to achieve national standards for glycemic control can be achieved with high probability, thus allowing for more efficient management of diabetes.

    Title Diabetes in Urban African-americans. Xvii. Availability of Rapid Hba1c Measurements Enhances Clinical Decision-making.
    Date November 1999
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: To assess the impact of rapid-turnaround HbA1c results on providers' clinical decision-making and on follow-up HbA1c levels. RESEARCH DESIGN AND METHODS: The research design was a randomized clinical trial in which rapid HbA1c results were made available to providers on even days of the month (rapid, n = 575), but delayed by 24 h on odd days (conventional, n = 563). Adjustment of therapy for patients with type 2 diabetes was considered appropriate if therapy was intensified for HbA1c values >7% or not intensified for HbA1c values < or =7%. A post-hoc analysis was also performed using patients (n = 574) who returned for follow-up 2-7 months later to ascertain the effect of rapid HbA1c availability on subsequent glycemic control. RESULTS: Rapid HbA1c availability resulted in more appropriate management compared with conventional HbA1c availability (79 vs. 71%, P = 0.003). This difference was due mainly to less frequent intensification when HbA1c levels were < or =7% (10 vs. 22%, P < 0.0001) and slightly to more frequent intensification for patients with HbA1c values >7% (67 vs. 63%, P = 0.33). For both groups, intensification was greatest for patients on insulin (51%) compared with patients on oral agents (35%) and diet alone (14%) (P < 0.0001). Regression analysis confirmed that providers receiving conventional HbA1c results were more likely to intensify therapy in patients who already had HbA1c levels < or =7%. Over 2-7 months of follow-up, HbA1c rose more in patients with conventional HbA1c results compared with rapid results (0.8 vs. 0.4%, P = 0.02). In patients with initial HbA1c >7%, rapid HbA1c results had a favorable impact on follow-up HbA1c independent of the decision to intensify therapy (P = 0.03). CONCLUSIONS: Availability of rapid HbA1c determinations appears to facilitate diabetes management. The more favorable follow-up HbA1c profile in the rapid HbA1c group occurs independently of the decision to intensify therapy, suggesting the involvement of other factors such as enhanced provider and/or patient motivation.

    Title Diabetes in Urban African-americans. Xvi. Overcoming Clinical Inertia Improves Glycemic Control in Patients with Type 2 Diabetes.
    Date November 1999
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: Diabetes care can be limited by clinical inertia-failure of the provider to intensify therapy when glucose levels are high. Although disease management programs have been proposed as a means to improve diabetes care, there are few studies examining their effectiveness in patient populations that have traditionally been underserved. We examined the impact of our management program in the Grady Diabetes Unit, which provides care primarily to urban African-American patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: We assessed glycemic outcomes in patients with type 2 diabetes who had an intake evaluation between 1992 and 1996 and who were identified on the basis of compliance with keeping the recommended number of return visits. For 698 patients, we analyzed changes in HbA1c values between baseline and follow-up visits at 6 and 12 months, and the proportion of patients achieving a target value of < or =7.0% at 12 months. Since a greater emphasis on therapeutic intensification began in 1995, we also compared HbA1c values and clinical management in 1995-1996 with that of 1992-1994. RESULTS: HbA1c averaged 9.3% on presentation. After 12 months of care, HbA1c values averaged 8.2, 8.4, 8.5, 7.7, and 7.3% for the 1992-1996 cohorts, respectively, and were significantly lower compared with values on presentation (P < 0.0025); the average fall in HbA1c was 1.4%. The percentage of patients achieving a target HbA1c < or =7.0% improved progressively from 1993 to 1996, with 57% of the patients attaining this goal in 1996. Mean HbA1c after 12 months was 7.6% in 1995-1996, significantly improved over the level of 8.4% in 1992-1994 (P < 0.0001). HbA1c levels after 12 months of care were lower in 1995-1996 versus 1992-1994, whether patients were managed with diet alone, oral agents, or insulin (P < 0.02). Improved HbA1c in 1995-1996 versus 1992-1994 was associated with increased use of pharmacologic therapy CONCLUSIONS: Structured programs can improve glycemic control in urban African-Americans with diabetes. Self-examination of performance focused on overcoming clinical inertia is essential to progressive upgrading of care.

    Title Diabetes and Obesity in the Louisiana Coushatta Indians.
    Date July 1999
    Journal Ethnicity & Disease
    Excerpt

    OBJECTIVE: In order to assist their community in planning intervention and prevention programs, prevalence rates for diabetes and obesity were examined among the Louisiana Coushatta. RESEARCH DESIGN AND METHODS: Coushatta individuals participated in a health survey (questionnaires and physical examinations). Those without known diabetes underwent oral glucose tolerance testing and were classified as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT), or diabetes mellitus (DM). Those with known DM had the diagnosis confirmed by history and/or elevated hemoglobin A1c. Waist-to-hip ratio (WHR), body mass index (BMI), and percent body fat (%BF) were determined as measures of central adiposity and obesity. Prevalence rates of diabetes and obesity among those examined were calculated. The prevalence of those with more than one anthropometric index positive for obesity was also determined. RESULTS: The prevalence of DM was 30% and IGT was 17% among the first 151 Coushatta participants. For males, the prevalence of obesity was 62%, 57%, and 52%, and for females, 59%, 54%, 45%, as determined by the BMI, %BF, and WHR, respectively. Obesity was more prevalent among those with glucose intolerance (IGT + DM) than those with NGT, and those who were obese had the highest prevalence of glucose intolerance. A greater percentage of those with glucose intolerance had more than one positive obesity measure as compared to those with NGT, and those with more than one index consistent with obesity had a greater prevalence of IGT + DM. CONCLUSIONS: Prevalence rates of DM and obesity are high among the Louisiana Coushatta, and obesity is associated with glucose intolerance. Clustering of the three obesity measures occurs in a high percentage of individuals. Data from the current survey are providing information that is being used by the Coushatta community for health planning and development of intervention and prevention programs.

    Title What Do Internal Medicine Residents Need to Enhance Their Diabetes Care?
    Date July 1999
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: To identify areas that should be targeted for improvement in care, we examined internal medicine resident practice patterns and beliefs regarding diabetes in a large urban hospital outpatient clinic. RESEARCH DESIGN AND METHODS: Internal medicine residents were surveyed to assess the frequency at which they performed key diabetes quality of care indicators. Responses were compared with recorded performance derived from chart and laboratory database reviews. Resident attitudes about diabetes were determined using the Diabetes Attitude Survey for Practitioners. Finally, an eight-item scale was used to assess barriers to diabetes care. RESULTS: Both self-described and recorded performance of recommended diabetes services short of national recommendations. For yearly eye examinations and lipid screening, recorded performance levels were similar to trainees' reports. However, documented inquiries about patient self-monitoring of blood glucose, performance of foot examinations, and urine protein screening were lower than trainees' reports. Some 49% of the residents selected a target HbA1c of 6.6-7.5% as an attainable goal, yet half of the patients using oral agents or insulin had HbA1c values > 8.0%. No differences in self-described or recorded performance were found by year of training. Most residents did not perceive themselves to need additional training related to diabetes care, and residents were generally neutral about patient autonomy. Patient nonadherence and time constraints within the clinic were most often cited as barriers to care. CONCLUSIONS: The study identifies several areas that require improvement in resident care of diabetes in the ambulatory setting. Because experience during training contributes to future practice patterns, developing a program that teaches trainees how to implement diabetes practice guidelines and methods to achieve optimal glycemic control may be key to future improvements in the quality of diabetes care.

    Title Genetic Studies Suggest a Multicentric Origin for Hb G-coushatta [beta22(b4)glu-->ala].
    Date June 1999
    Journal Hemoglobin
    Excerpt

    Hb G-Coushatta [beta22(B4)Glu-->Ala] is found in geographically separated ethnic groups. Commonest along the Silk Road region of China but also present in the North American Coushatta, we sought to determine whether this variant had a unicentric or multicentric origin. We examined the haplotype of the beta-globin gene cluster in two Chinese families and in five Louisiana Coushatta heterozygous for this mutation. Chinese and Louisiana Coushatta had different haplotypes associated with the identical Hb G mutation. These haplotypes were defined by the presence of a HindIII restriction site in the Agamma-globin gene and AvaII restriction site in the beta-globin gene in Chinese subjects and their absence in the Louisiana Coushatta. We found a CAC at codon beta2 (beta-globin gene framework 1 or 2) linked to the Hb G-Coushatta gene in Chinese, and a CAT (framework 3) in Louisiana Coushatta, indicating different beta-globin gene frameworks. Both the Hb G-Coushatta mutation (GAA-->GCA) and the codon 2 CAC-->CAT polymorphism are normal delta-globin gene sequences, suggesting the possibility of gene conversion. We conclude that Hb G-Coushatta had at least two independent origins. This could be due to separate mutations at codon beta22 in Chinese and Louisiana Coushatta, a mutation at this codon and a beta-->delta conversion, or two beta-->delta gene conversion events.

    Title Outpatient Diabetes Management of Medicare Beneficiaries in Four Mississippi Fee-for-service Primary Care Clinics.
    Date February 1999
    Journal Journal of the Mississippi State Medical Association
    Excerpt

    BACKGROUND: As part of a quality improvement initiative aimed at increasing physician compliance with standards of care for diabetes patients, diabetes practice patterns among Medicare beneficiaries in four primary care clinics were examined in Mississippi. METHODS: Retrospective chart reviews of Medicare beneficiaries with a diagnosis of diabetes were conducted to examine physician compliance with recommended diabetes monitoring services. RESULTS: Fifty-three percent of all beneficiaries did not have a recorded A1c test while 54 percent did not have a recorded foot exam. The percentage without foot exams decreased with quarterly visits. Seventy-two percent and 68 percent of patients had testing for lipids and proteinuria, respectively, although variability in types of testing performed was seen. Seventy-six percent of beneficiaries did not have a referral for a dilated eye exam. CONCLUSIONS: The study has uncovered, within several primary care sites in Mississippi, variable documentation of compliance with many clinically relevant recommendations relating to the care of elderly patients with diabetes. These items can be targeted for improvement as part of a statewide quality improvement initiative for Medicare beneficiaries.

    Title Use of the Physician Insurers Association of America Database As a Surveillance Tool for Diabetes-related Malpractice Claims in the U.s.
    Date September 1998
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: To examine the available national surveillance data on malpractice claims associated with diabetes and to determine the medical specialties having the highest number of claims and the classes and costs of filed claims relating to diabetes. RESEARCH DESIGN AND METHODS: Data was abstracted from the Data Sharing Reports (DSRs) of the Physicians Insurers Association of America (PIAA), as well as a search of the PIAA's computerized database for the period spanning 1 January 1985 to 31 December 1996. Data on numbers of claims, medical causes of loss, indemnity paid, demographics of claimants and physicians, severity, and medical specialties with diabetes-related claims were available. RESULTS: A total of 906 diabetes claims were reported to PIAA, and the total indemnity paid was $26,892,848. A significant downward trend (P = 0.004) was noted for the period between 1993 and 1996. Diabetes claimants were older and predominantly male, relative to all claimants. Ophthalmology, internal medicine, and general and family practice had the highest rates of reported claims at 16.5, 13.6, and 13.4 diabetes claims per 1,000 claims, respectively. Of the diabetes-related injuries, 44% occurred in the practitioners office, as compared with 27% for all claims. A greater proportion of diabetes claims were associated with the highest level of severity of injury with respect to all claims compiled by the PIAA. CONCLUSIONS: The database of the PIAA can be a useful resource to monitor trends in diabetes-related malpractice. Further study into whether claims result from lack of adherence to practice guidelines is needed. Prevention programs designed to reduce the liability among high-risk specialties may also lead to improved care for the patient with diabetes.

    Title Comparison of Four Commercial Urinary Albumin (microalbumin) Methods: Implications for Detecting Diabetic Nephropathy Using Random Urine Specimens.
    Date August 1998
    Journal Clinica Chimica Acta; International Journal of Clinical Chemistry
    Excerpt

    The results of four urinary albumin methods used to identify patients with early diabetic renal disease were compared using random urine samples from healthy and diabetic patients. These methods were the Beckman Array and Behring BNAI immunonephelometric methods, the Dade aca particle-enhanced turbidimetric inhibition immunoassay method, and the INCSTAR SPQ immunoturbidimetric method. The albumin/creatinine ratio reference interval was found to be 2-20 mg albumin/g creatinine (mg/g) for the Array and 3.5-27.5 mg/g for the aca method. All four methods were compared using urines from a group of diabetic and nondiabetic patients. The BNAI, SPQ and Array methods compared well with one another while the aca demonstrated a positive bias of almost 60% at the 30 mg/g and 300 mg/g levels with certain lots of reagent and calibrator. Calibrator cross-over experiments demonstrated that some of the positive bias of the aca method could be accounted for by calibrator differences.

    Title Effects of Sickle Cell Trait and Hemoglobin C Trait on Determinations of Hba1c by an Immunoassay Method.
    Date July 1998
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: A number of studies, including the Diabetes Control and Complications Trial (DCCT), have shown that good glycemic control, as assessed by GHb measurements, can reduce the chronic complications of diabetes. The National Glycohemoglobin Standardization Program (NGSP) was established to insure that GHb measurements by different methods were comparable and could be related to the candidate reference method used in the DCCT. The measurement of HbA1c in patients with Hb variants is one area not directly addressed by the NGSP. Therefore, we assessed the comparability of two DCCT-traceable methods in samples with Hb variants. RESEARCH DESIGN AND METHODS: Samples containing HbAA, HbAC, and HbAS were collected from diabetic and nondiabetic patients. HbA1c concentrations were measured by a high-performance liquid chromatography method (Bio-Rad Diamat) and an immunoassay that is suitable for use in a physician's office (Bayer DCA 2000). RESULTS: The two methods compared well for samples with HbAA and HbAS. However, for samples containing HbAC the immunoassay method showed relative positive biases of 8.4 and 10.4% at HbA1c levels of 7 and 9%, respectively, such that the two methods would not be judged comparable according to NGSP guidelines. CONCLUSIONS: The DCA 2000 HbA1c immunoassay method showed significant positive bias in patients with HbC trait. One possible clinical implication of this overestimation is overly rigorous glycemic control with a concomitant increase in hypoglycemia. This may be especially important in certain ethnic populations, such as African-Americans, who have a relatively high prevalence of HbC trait.

    Title Caloric Intake and Weight Gain of Rats Depends on Endogenous Fat Preference.
    Date July 1997
    Journal Physiology & Behavior
    Excerpt

    Within outbred colonies, subpopulations of rats exist that exhibit inherent preferences for one type of macronutrient over another (e.g., fat vs. carbohydrate). Prior investigations into the effect of dietary manipulations on consumption or weight gain have not taken into account endogenous macronutrient preferences. The purpose of this study was to examine whether inherent fat preferences translate into differences in caloric consumption and weight gain in rats when fed high-fat and high-carbohydrate diets. Rats that exhibited a preference for fat were identified using a previously described paradigm and were subsequently placed on either a high-fat or high-carbohydrate diet. Daily caloric intakes and weekly weights were monitored over a 28-day period and compared with data for animals with a low-fat preference on the same diets. By the conclusion of the study, the low-fat-preferring rats on the high-carbohydrate diet had consumed significantly more calories than the high-fat-preferrers maintained on the same diet. In contrast, the amounts of calories consumed on the high-fat diet were not significantly different between the low- and high-fat-preferring animals. Those animals with a preference for fat placed on a high-carbohydrate diet weighed significantly less by the end of study, even though they consumed the same number of calories as animals on the high-fat diet. We conclude that the outcome of nutritional studies designed to examine caloric intake and weight gain can be influenced by the innate macronutrient preference of the animal.

    Title Lipoprotein (a) Levels in African-americans with Niddm.
    Date February 1997
    Journal Diabetes Care
    Excerpt

    OBJECTIVE: The purpose of this study was to investigate possible relationships between lipoprotein (a) [Lp(a)] levels and NIDDM in African-Americans. The objectives were to identify associations between Lp(a) levels of subjects with and without NIDDM and to determine the influence of glycemic control, determined by GHb, and of mode of therapy on Lp(a) levels. RESEARCH DESIGN AND METHODS: We studied [4] African-American subjects, 103 with NIDDM and 38 without NIDDM. Their Lp(a) levels, GHb levels, and apolipoprotein (a) [apo(a)] isoforms were determined. Clinical information, including mode of therapy (sulfonylurea, insulin, or no pharmacological therapy), date of diagnosis, and medical history, was obtained by chart review and patient interview. RESULTS: There was no significant difference in median Lp(a) levels between the non-NIDDM (25.5 mg/dl) and NIDDM (24.0 mg/dl) study subjects. No statistically significant difference was found in Lp(a) levels when NIDDM patients with GHb < 12.3% were compared to those with GHb > or = 12.3% (P = 0.096). An inverse relationship was found between apo(a) root-mean-square isoform size and Lp(a) level (r2 = 0.091, P = 0.0035). Analysis of the cases by mode of therapy indicates that there is evidence of an increased median level of Lp(a) in African-Americans with NIDDM on insulin therapy relative to those on sulfonylurea (34.0 vs. 16.0 mg/dl; P = 0.013) and to nondiabetic subjects (34.0 vs. 25.5 mg/dl; P = 0.043). CONCLUSIONS: We conclude that the level of plasma Lp(a) is higher in African-Americans with NIDDM who are being treated with insulin when compared to those on sulfonylurea therapy and to those who are non-NIDDM subjects, and this does not seem to be due to genetic variance or method bias.

    Title A Comparison of Two Commercially Available in Vitro Chemosensitivity Assays.
    Date September 1995
    Journal Oncology
    Excerpt

    In vitro chemosensitivity assays (IVCAs) are expensive laboratory tests utilized to assist oncologists in the selection of chemotherapeutic regimens. Their utility is disputed; yet, these assays continue to be requested because of the importance of the information they can provide and their scientifically logical approach. Therefore, we compared the results of two assays offered to clinicians at our hospital; the extreme drug resistance assay performed by Oncotech (OT) and the fluorescent cytoprint assays performed by Analytical Biosystems (AB). The two techniques used and the expression of assay results by the two companies are discussed. Twenty neoplasms, all at least 3 cm in diameter and predominantly of breast and ovarian origin, were compared. OT performed 74 drug assays on 17 tumors, while AB performed 194 assays on the corresponding neoplasms; 3 neoplasms were insufficient for comparison. Evaluation of the results revealed apparent disagreement on at least 44 drug assays with complete disagreement on at least 2 of the drugs tested in 12 of 17 cases. In conclusion, based on available information, comparisons between IVCAs show great variation in results; prospective studies are needed to evaluate commercially available assays for correlation with clinical outcome, and results should be expressed so comparisons can be readily made. Though utility may be limited to tumors resistant to standard therapy, cost and benefit to the patient will ultimately determine the fate of these tests.

    Title Epididymal Fat Depot Lipoprotein Lipase Activity is Lower in Animals with High Endogenous Fat Preferences.
    Date September 1995
    Journal Life Sciences
    Excerpt

    Adipose tissue lipoprotein lipase (LPL) is a key enzyme responsible for the clearance of circulating triglycerides and has been linked to certain pathologic states such as obesity. In order to investigate whether an animal's endogenous fat-preference is associated with differences in adipose tissue LPL, we measured enzyme activity in epididymal fat from high- and low-fat preferring rats. Utilizing a 24h ad libitum feeding paradigm, four groups of outbred adult male Sprague-Dawley rats were screened separately for their macronutrient preferences. Animals exhibiting high- or low-fat preferences were identified and placed back on standard chow. LPL activity was measured in epididymal fat under chow fed or fasted conditions. Epididymal fat LPL activity was significantly less in the high-fat-preferring animals relative to the low-fat-preferring, in both the standard chow-fed state (p = 0.014) and fasted (p = 0.0007) state. LPL activity in heart ventricle and brown adipose tissue was also measured from the same animals. Activity in heart ventricle and brown adipose tissue was significantly lower in the high-fat-preferring group as compared with the low-fat-preferring only following a 24h fast (p = 0.0012 for heart and p = 0.0085 for brown adipose, high- versus low-fat preferring). The data indicate that differences in tissue LPL activity exist between animals with inherent differences in fat preference. Future comparative studies between the two groups of fat-preferring animals could lead to important clues to the regulation of the LPL.

    Title Excessive Urinary Excretion of Zinc in Drug Addicts: a Preliminary Study During Methadone Detoxification.
    Date August 1995
    Journal Journal of Trace Elements and Electrolytes in Health and Disease
    Excerpt

    Random samples of urine from control subjects, and subjects treated with methadone (an agonist of morphine) for drug addiction, were analyzed for calcium and trace elements zinc and copper. The following differences (based on creatinine) were observed between the two groups: Calcium excretion did not show any significant differences between the two groups (146 mmg/g creatinine vs. 135 mg/g creatinine vs. 33 +/- 3 micrograms/g creatinine in controls). However, the excretion of copper in drug addicts diminished (23 +/- 3 micrograms/g creatinine in controls; p < 0.05), while that of zinc was excessive (600 +/- 50 micrograms/g creatinine vs. 300 +/- 30 micrograms/g creatinine in controls; p < 0.001). The ever increasing link between zinc and immunity and the fact that drug addicts are susceptible to various infections such as hepatitis and acquired immuno deficiency syndrome raises concern about the excessive urinary loss of zinc in this group and calls for further investigations such as balance studies and intervention if necessary.

    Title Measurement and Seasonal Variations of Black Bear Adipose Lipoprotein Lipase Activity.
    Date May 1995
    Journal Physiology & Behavior
    Excerpt

    The black bear (Ursus americanus) provides a unique model for the study of adipose physiology because it exhibits seasonal periods of rapid weight gain and weight loss without marked changes in its metabolic rate. To better understand fat cycling in this model, we obtained plasma and gluteal adipose tissue from five captive adult bears at approximately 20-day intervals from October 1 1992 through March 31 1993. The study included a predenning and denning period for each animal. Sampling during the predenning period followed a 12-h fast. Bears were anorectic while denning. Adipose LPL activities and plasma insulin concentrations were determined for each time point. Predenning LPL activities (4.83 +/- 0.64 mumol/h/g) were significantly greater than those seen during the denning period (1.82 +/- 0.65, p < 0.001). A biphasic pattern of fasting LPL activity was seen in four of the five bears during the predenning period. Fasting insulin concentrations showed no such pattern of variation during the study period (mean = 25.1 +/- 1.36 pmol/l; range 1.1-6.0). We found no evidence of a linear relationship between LPL activity and insulin levels (p = 0.139). Neither LPL activity nor insulin concentrations were related to changes in weight (p = 0.257 and p = 0.7104, respectively). We conclude that LPL activity can be measured in black bear adipose tissue and that fall (predenning) activities are significantly higher than those seen during the winter (denning period). Furthermore, the seasonal regulation of LPL involves some factor(s) in addition to insulin.

    Title Rapid Diagnosis of Enterohemorrhagic Escherichia Coli O157:h7 Directly from Fecal Specimens Using Immunofluorescence Stain.
    Date February 1994
    Journal American Journal of Clinical Pathology
    Excerpt

    Serotype O157:H7 is most frequently encountered among verotoxin-producing Escherichia coli. Most laboratories use MacConkey-sorbitol agar as a screening medium. Presumptive identification of sorbitol-negative colonies is then accomplished by latex agglutination or biochemical tests with serologic confirmation, which requires 18-36 hours for completion. This study attempted to detect E coli O157:H7 directly from stool specimens by direct immunofluorescence (DIF) antibody staining to provide quicker turnaround (< 2 hours). A total of 336 abnormal fecal samples (bloody, watery, semi-liquid, or mucoid) were examined by this method. Results were compared with those of culture. Direct immunofluorescence antibody staining of the direct fecal smear detected all isolates of E coli O157 that were recovered by culture, including nonmotile strains, strains possessing the H7 flagellar antigen, and one strain with a flagellar antigen other than H7. Optimum results were achieved when specimens were pretreated with 5% bleach and centrifugation. No false-negative results were obtained with bleach-pretreated stool samples.

    Title Primary Bronchopulmonary Fibrosarcoma of the Trachea in a Child.
    Date December 1993
    Journal Southern Medical Journal
    Excerpt

    We have reported the unusual case of a 7-year-old boy who was admitted with respiratory symptoms of several months' duration. He was found to have a tumor of the trachea, which proved to be a low-grade fibrosarcoma with smooth muscle differentiation.

    Title Expression of Thyroid Hormone Receptor Beta 2 in Rat Hypothalamus.
    Date March 1992
    Journal Endocrinology
    Excerpt

    A polymerase chain reaction based assay was used to evaluate expression of thyroid hormone receptor beta 2 mRNA in rat hypothalamus. Expression was detected in the arcuate, ventromedial and paraventricular nuclei, as well as the median eminence. Trace expression was found in the dorsomedial nucleus, but no expression of thyroid hormone receptor beta 2 was detected in the lateral hypothalamus or the preoptic region. The results indicate that, contrary to previous belief, expression of thyroid hormone receptor beta 2 is not confined to the anterior pituitary.

    Title Naloxone Increases the Frequency of Pulsatile Luteinizing Hormone Secretion in Women with Hyperprolactinemia.
    Date December 1991
    Journal The Journal of Clinical Endocrinology and Metabolism
    Excerpt

    The ability to change the frequency and amplitude of pulsatile GnRH secretion may be an important mechanism in maintaining regular ovulatory cycles. Hyperprolactinemia is associated with anovulation and slow frequency LH (GnRH) secretion in women. To assess whether the slow frequency of LH (GnRH) secretion is due to increased opioid activity, we examined the effect of naloxone infusions in eight amenorrheic hyperprolactinemic women (mean +/- SE, serum PRL, 160 +/- 59 micrograms/L). After a baseline period, either saline or naloxone was infused for 8 h on separate days, and LH was measured in blood obtained at 15-min intervals. Additional samples were obtained for plasma FSH, PRL, estradiol, and progesterone. Responses to exogenous GnRH were assessed at the end of the infusions. LH pulse frequency increased in all subjects from a mean of 4.0 +/- 0.5 pulses/10 h (mean +/- SE) during saline infusion to 8.0 +/- 1.0 pulses/10 h during naloxone infusion (P less than 0.01). LH pulse amplitude did not change, and mean plasma LH increased from 7.4 +/- 0.8 IU/L (+/- SE) to 11.2 +/- 1.5 IU/L during naloxone (P less than 0.01). A small but significant increase was seen in mean plasma FSH. Plasma PRL, estradiol, and progesterone were unchanged by naloxone infusion. These data suggest that elevated serum PRL reduces the frequency of LH (GnRH) secretion by increasing hypothalamic opioid activity and suggest that the anovulation in hyperprolactinemia is consequent upon persistent slow frequency LH (GnRH) secretion.

    Title Expression of Erba Alpha and Beta Mrnas in Regions of Adult Rat Brain.
    Date June 1990
    Journal Molecular and Cellular Endocrinology
    Excerpt

    The proto-oncogenes erbA alpha and erbA beta together encode three functional thyroid hormone receptors (erbA alpha 1, beta 1, and beta 2), as well as two proteins (erbA alpha 2 and alpha 3) that do not bind T3. The erbA alpha 2 protein has been shown to inhibit the T3 inductive effects of functional receptors, and alpha 2 mRNA is expressed at high levels in adult rat brain. Thus, expression of erbA alpha 2 may explain the observation that adult rat brain is not a T3 responsive organ, despite the presence of T3 receptors. However, expression of the different erbA mRNAs has not been studied within distinct regions of rat brain. To gain further insight into the roles of these molecules, we have used polymerase chain reaction to investigate the expression of all five erbA mRNAs within discrete regions of adult rat brain. The results indicate that all three erbA alpha mRNAs are expressed in all regions studied (brainstem, cerebellum, cortex, hippocampus, pituitary, quadrigeminal plate, striatum, and thalamus). All regions contained less erbA alpha 3 RNA than either alpha 1 or alpha 2. Expression of alpha 2 exceeded that of alpha 1 in all regions except striatum. ErbA beta 1 was expressed in all brain regions, whereas erbA beta 2 was confined to the pituitary.

    Title Animal Research.
    Date April 1989
    Journal Virginia Medical
    Title Prostaglandin F2 Alpha Metabolite Levels in Normal and Uterine-infected Postpartum Cows.
    Date June 1988
    Journal Veterinary Research Communications
    Excerpt

    The stable metabolite of prostaglandin F2 alpha,15 keto-13,14-dihydroprostaglandin F2 alpha (PGFM), was measured from peripheral blood samples collected at specified intervals postpartum from 7 normal dairy cows and 4 cows with apparent endometritis. Plasma PFGM levels were significantly (P less than .05) elevated for the first 5 days postpartum in the cows with endometritis (ranging from 4.0 to 5.0 ng/ml) compared to the controls (approximately 1.0 ng/ml). Beyond 5 days postpartum, plasma PGFM levels were not significantly different and decreased to approximately 0.4 ng/ml by day 13 in both groups. Time to uterine involution was not different between groups (less than 30 days). Therefore, uterine infections in cows during the puerperium was associated with elevated circulating PGFM levels. These findings and the observation that PGF2 alpha is not uterotonic in the puerperal cow do not suggest a therapeutic use of PGF2 alpha in order to evacuate the uterus.

    Title Apheresis in a Community Hospital: Six Years' Experience.
    Date May 1987
    Journal Southern Medical Journal
    Excerpt

    We present our six-year experience with apheresis in a community hospital in northern Virginia. A total of 2,892 procedures were done, including 2,232 thrombocytaphereses on normal donors for collection of platelets and 660 therapeutic plasma exchanges in patients having a variety of disorders. We hope our experience will be helpful to those who contemplate setting up similar programs.

    Title Bacteriuria Screening by Leukocyte Esterase Nitrite Strip Plus Gram Stain.
    Date February 1986
    Journal Virginia Medical
    Title Effects of Renal Denervation on the Renal Responses of Anesthetized Rats to Cyclohexyladenosine.
    Date December 1984
    Journal Canadian Journal of Physiology and Pharmacology
    Excerpt

    In the present experiments, we tested the hypothesis that renal denervation would attenuate or abolish some of the renal effects of cyclohexyladenosine, a nonmetabolized adenosine receptor agonist. A paired design (left kidney sham-denervated or denervated versus the innervated right kidney) was used in anesthetized rats. Intravenous cyclohexyladenosine (2.3 nmol/min) reduced para-aminohippurate and inulin clearances in both denervated and sham-denervated kidneys; these effects were increased rather than decreased in denervated kidneys. Similarly, cyclohexyladenosine decreased the excretion of Na+ and K+ more in denervated than in innervated kidneys. Renal plasma flow was decreased by cyclohexyladenosine, without a corresponding increase in the arteriorenal venous difference in plasma renin concentrations, and arterial plasma renin concentration decreased in all rats given cyclohexyladenosine, suggesting inhibition of renin secretion. No differences in the latter variables were noted in denervated versus sham-denervated kidneys. Since cyclohexyladenosine produced effects in denervated kidneys which were equal to or greater than the effects in sham-denervated kidneys, it is concluded that these effects are mediated by direct actions, rather than by inhibition of transmitter release from the renal nerves.

    Title Rapid Detection of Insignificant Bacteriuria by Concomitant Use of Lumac System and Gram's Stain.
    Date November 1984
    Journal American Journal of Clinical Pathology
    Excerpt

    The Lumac system, which assays bacterial ATP by bioluminescence, is a rapid method (less than 1 hour) for detection of bacteriuria. Conventional culture by calibrated loop technic and the Lumac system were compared using 2,000 urine specimens. Interpretation of Gram's stains of uncentrifuged specimens in addition to results of the Lumac system provided a second comparison with culture. Using a criterion of greater than or equal to 10(4) CFU/mL, conventional culture yielded 17% of the 2,000 specimens positive for bacteriuria. By Lumac + smear 27% were positive opposed to 41% positive by the Lumac system alone. The Lumac + smear method produced sensitivity (97%), specificity (88%), positive predictive value (62%), and negative predictive value (99.3%). False negative rates by the Lumac alone and Lumac + smear were 0.65% and 0.5%, respectively.

    Title Rapid Recovery of Mycobacteria from Clinical Specimens Using Automated Radiometric Technic.
    Date April 1984
    Journal American Journal of Clinical Pathology
    Excerpt

    Automated radiometric technic (BACTEC Johnston Laboratories, Towson, MD) was compared with conventional mycobacterial culture procedure (Lowenstein-Jensen plus Gruft modification of Lowenstein-Jensen) in this study of 1,000 clinical specimens. In addition, 8-azaguanine inhibition was tested by radiometric technic as a rapid procedure for the differentiation of Mycobacterium tuberculosis from other mycobacterial species. A total of 59 mycobacteria was recovered. Of 28 clinically significant isolates (M. tuberculosis, M. kansasii, M. avium, M. fortuitum), the BACTEC system detected 26 (93%). Conventional methods recovered 23 (82%). The BACTEC system required an average of seven days to recover M. tuberculosis from smear-positive specimens compared with 18 days required by Lowenstein-Jensen or Gruft slants. From smear-negative specimens, the BACTEC detected M. tuberculosis in an average of 20 days versus 28 days by conventional procedure. All 20 isolates of M. tuberculosis were inhibited by 8-azaguanine, whereas 39 isolates of mycobacteria other than M. tuberculosis were not inhibited. The BACTEC system accomplishes more rapid recovery of mycobacteria and provides a higher yield than conventional methods.

    Title A Rapid Diagnosis of Campylobacter Enteritis by Direct Smear Examination.
    Date September 1983
    Journal American Journal of Clinical Pathology
    Excerpt

    Diagnosis of Campylobacter enteritis by direct smear examination of stool specimens, using 1% aqueous basic fuchsin, was compared with a conventional cultural method (Campy-BAP). After examination of 485 stool specimens the direct smear method produced a sensitivity and specificity of 94% and 99.5%, respectively.

    Title Perceived Stress & Situational Supports.
    Date December 1982
    Journal Nursing Management
    Title Adaptations to Endosymbiosis in Green Hydra.
    Date August 1981
    Journal Annals of the New York Academy of Sciences
    Title False Negative Hepatitis B Surface Antigen Detection in Dialysis Patients Due to Excess Surface Antigen: Postzone Phenomenon.
    Date January 1981
    Journal Journal of Clinical Pathology
    Excerpt

    Renal dialysis patients are well known to have a high incidence of hepatitis B carrier state. In studying a group of 63 long-term dialysis patients, 10 were found to be positive for hepatitis B surface antigen by radioimmunoassay (RIA). Surprisingly, however, only three of these RIA positive patients were positive by counter immunoelectrophoresis (CIEP). The discrepancy could not be accounted for by the difference in sensitivity of the two methods. The cause for the negative reactions by CIEP in seven patients was found to be the marked excess surface antigen in these sera which produced false negative results by the postzone phenomenon. After dilution all seven sera were positive by CIEP, requiring a dilution up to 1/20 to produce a positive result. Also, all seven sera were positive by the less sensitive Ouchterlony double diffusion.

    Title Endocytic Mechanisms of the Digestive Cells of Hydra Viridis. 1. Morphological Aspects.
    Date December 1979
    Journal Cytobios
    Excerpt

    The endocytic mechanisms of the digestive cells of Hydra viridis were examined by transmission electron microscopy. Algae which form a stable intracellular symbiosis are phagocytosed by uncoated plasmalemma, as are large (greater than 0.5 micron) food particles. Discoidal coated vesicles apparently effect the endocytosis of smaller particles, including macromolecules. Competition experiments indicate that the uptake of algae and larger food particles utilize similar endocytic membrane.

    Title Acidometric Agar Plate Method for Ampicillin Susceptibility Testing of Haemophilus Influenzae.
    Date June 1978
    Journal Antimicrobial Agents and Chemotherapy
    Excerpt

    The need for an accurate and rapid method of testing ampicillin susceptibility of Haemophilus influenzae, especially strains isolated from patients with meningitis and septicemia, is indisputable. Various methods have been employed for this purpose. Each has advantages and disadvantages. This report describes a modification of the capillary acidometric procedure in which an agar plate is substituted for a tube. All beta-lactamase results obtained by this modified technique correlated with minimal inhibitory concentrations determined in liquid media and the chromogenic cephalosporin substrate method. This modified acidometric agar procedure is a simple, inexpensive, accurate, and rapid way to determine H. influenzae susceptibility to ampicillin.

    Title The Value of Blood Component Therapy.
    Date August 1977
    Journal Virginia Medical
    Title Uptake, Recognition and Maintenance of Symbiotic Chlorella by Hydra Viridis.
    Date October 1976
    Journal Symposia of the Society for Experimental Biology
    Title Single Image Pericardial Effusion Evaluation with Technetium Compounds.
    Date June 1975
    Journal Southern Medical Journal
    Excerpt

    Three cases of suspected pericardial effusion were evaluated with rapid, noninvasive procedure, combined use of macroaggregated albumin technetium 99m and human serum albumin technetium 99m to produce a single radiography showing the heart, liver, and lung perfusion simultaneously. This technic confirmed the diagnosis of pericardial effusion in two cases and ruled out this possibility in the third case.

    Title Radioisotope Scintigraphy in Osteomyelitis.
    Date November 1974
    Journal Virginia Medical Monthly
    Title Antibiotic Sensitivity of Salmonella and Shigella.
    Date September 1974
    Journal Virginia Medical Monthly
    Title Septicemia and Gastroenteritis Due to Vibrio Fetus.
    Date June 1973
    Journal Southern Medical Journal
    Title Cutaneous Sporotrichosis: Recent Appearance in Northern Virginia.
    Date April 1972
    Journal American Journal of Clinical Pathology
    Title Free Thyroxine Indices.
    Date February 1972
    Journal The Medical Annals of the District of Columbia
    Title Identification of Haemophilus Vaginalis.
    Date June 1968
    Journal Technical Bulletin of the Registry of Medical Technologists
    Title Idiopathic Uterine Hypertrophy.
    Date May 1968
    Journal Southern Medical Journal
    Title The Role of Symbiotic Dinoflagellates in the Temperature-induced Bleaching Response of the Subtropical Sea Anemone Aiptasia Pallida.
    Date
    Journal Journal of Experimental Marine Biology and Ecology
    Excerpt

    Coral bleaching involves the loss of symbiotic dinoflagellates (zooxanthellae) from reef corals and other cnidarians and may be a stress response of the host, algae or both. To determine the role of zooxanthellae in the bleaching process, aposymbiotic sea anemones from Bermuda (Aiptasia pallida) were infected with symbionts from other sea anemones (Aiptasia pallida from Florida, Bartholomea annulata and Condylactis gigantea). The expulsion of algae was measured during 24-h incubations at 25, 32 and 34 degrees C. Photosynthetic rates of freshly isolated zooxanthellae were also measured at these temperatures. The C. gigantea (Cg) symbionts were expelled in higher numbers than the other algae at 32 degrees C. Photosynthesis by the Cg algae was completely inhibited at this temperature, in contrast to the other symbionts. At 34 degrees all of the symbionts had increased expulsion rates, and at this temperature only the symbionts from Florida A. pallida exhibited any photosynthesis. These results provide the first evidence that the differential release of symbionts from the same host species is related to decreased photosynthesis at elevated temperatures, and support other findings suggesting that zooxanthellae are directly affected by elevated temperatures during bleaching events.

    Title Photoacclimation and the Effect of the Symbiotic Environment on the Photosynthetic Response of Symbiotic Dinoflagellates in the Tropical Marine Hydroid Myrionema Amboinense.
    Date
    Journal Journal of Experimental Marine Biology and Ecology
    Excerpt

    Symbiotic dinoflagellates of the genus Symbiodinium and residing in the tropical hydroid Myrionema amboinense acclimate to low photon flux associated with low light 'shade' environments by increasing the amount of photosynthetic pigments per algal cell. The photosynthetic light intensity (PI) curves suggested that the low-light pigment response involved an increase in the number of photosynthetic units (PSU) in the chloroplast in addition to any increases in PSU size. Comparisons of light-dependent portion of the P-I curves of freshly isolated zooxanthellae (FIZ) with those from symbionts within the intact animal suggest that the host cell environment reduced average light levels reaching the symbiotic algae by more than half. This phenomenon may protect the algae from photobleaching of pigments and/or photoinhibition of photosynthesis at high light intensities present in shallow water habitats. In addition, maximum photosynthesis (P(max)) of symbionts removed from the host cell was higher than that recorded from dinoflagellates in the intact association, suggesting that the availability of carbon dioxide for photosynthesis may be limited in the intact hydroid. Shaded polyps contained fewer zooxanthellae and had less tissue biomass (measured as protein) than unshaded polyps. However symbionts from shaded polyps acclimated to the low light intensities by increasing chlorophyll levels and photosynthetic rates. The higher photosynthetic rates may have resulted from increased availability of carbon dioxide associated with lower symbiont density. Calculations of the contribution of zooxanthellae carbon to the host animal's respiratory demand (CZAR) showed that zooxanthellae from shaded polyps living in the field potentially provide about the same amount of carbon to their host as zooxanthellae from polyps living in the field in unshaded high light intensities.

    Title Diabetes Management in Urban African Americans: Review of a Public Hospital Experience.
    Date
    Journal Ethnicity & Disease
    Excerpt

    OBJECTIVE: To review characteristics of an urban (primarily African American) diabetes patient population and discuss experience with treatment strategies, we summarize key retrospective and prospective analyses conducted during 15 years. RESULTS: Severe socioeconomic and personal barriers to diabetes care were often seen in the population. An atypical presentation of diabetic ketoacidosis was observed and extensively studied. A structured diabetes care delivery program was implemented more than three decades ago. A better understanding of how to provide simpler but effective dietary education and factors that affect lipid levels were elucidated. The phenomenon of clinical inertia was described, and methods were developed to facilitate the intensification of diabetes therapy and improve glycemic control. CONCLUSIONS: Structured diabetes care can be successfully introduced into a public health system and effective diabetes management can be provided to an under-served population that can result in improved metabolic outcomes. Lessons learned on diabetes management in this population can be extended to similar clinical settings.

    Title Insulin Pump Therapy in Patients with Diabetes Undergoing Surgery.
    Date
    Journal Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists
    Excerpt

    To assess perioperative management of patients with diabetes mellitus who were being treated with insulin pump therapy.

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