Showing papers by "Marshall H. Chin published in 2004"

Prevention or delay of type 2 diabetes.

Abstract: Diabetes is one of the most costly and burdensome chronic diseases of our time and is a condition that is increasing in epidemic proportions in the U.S. and throughout the world.1 The complications resulting from the disease are a significant cause of morbidity and mortality and are associated with the damage or failure of various organs such as the eyes, kidneys, and nerves. Individuals with type 2 diabetes are also at a significantly higher risk for coronary heart disease, peripheral vascular disease, and stroke, and they have a greater likelihood of having hypertension, dyslipidemia, and obesity.2–6 There is also growing evidence that at glucose levels above normal but below the threshold diagnostic for diabetes, there is a substantially increased risk of cardiovascular disease (CVD) and death.5,7–10 In these individuals, CVD risk factors are also more prevalent,5–7,9,11–14 which further increases the risk but is not sufficient to totally explain it. In contrast to the clear benefit of glucose lowering to prevent or retard the progression of microvascular complications associated with diabetes,15–18,21 it is less clear whether the high rate of CVD in people with impaired glucose homeostasis, i.e., those with impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or diabetes, is caused by elevated blood glucose levels or will respond to treatments that lower blood glucose. Epidemiological studies have shown a clear relationship,19,20 whereas intervention trials in people with diabetes suggest, but have not demonstrated, a clear benefit of glycemic control.15,16,21,22 Additionally, there are no studies that have investigated a benefit of glucose lowering on macrovascular disease in subjects with only IFG or IGT but not diabetes. Although the treatment of diabetes has become increasingly sophisticated, with over a dozen pharmacological agents available to lower blood glucose, a multitude of ancillary supplies and equipment available, and a clear recognition by health care professionals and patients that diabetes is a serious disease, the normalization of blood glucose for any appreciable period of time is seldom achieved.23 In addition, in well-controlled so-called “intensively” treated patients, serious complications still occur,15–18,21 and the economic and personal burden of diabetes remains. Furthermore, microvascular disease is already present in many individuals with undiagnosed or newly diagnosed type 2 diabetes.11,24–28 Given these facts, it is not surprising that studies have been initiated in the last decade to determine the feasibility and benefit of various strategies to prevent or delay the onset of type 2 diabetes. Two early reports29,30 suggested that changes in lifestyle can prevent diabetes, but weaknesses in study design limited their general relevance. Recently, however, four welldesigned randomized controlled trials have been reported.31–35 In the Finnish study,31 522 middleaged (mean age 55 years) obese (mean BMI 31 kg/m2) subjects with IGT were randomized to receive either brief diet and exercise counseling (control group) or intensive individualized instruction on weight reduction, food intake, and guidance on increasing physical activity (intervention group). After an average followup of 3.2 years, there was a 58% relative reduction in the incidence of diabetes in the intervention group compared with the control subjects. A strong correlation was also seen between the ability to stop the progression to diabetes and the degree to which subjects were able to achieve one or more of the following: lose weight (goal of 5.0% weight reduction), reduce fat intake (goal of <30% of calories), reduce saturated fat intake (goal of <10% of calories), increase fiber intake (goal of ≥15 g/1,000 kcal), and exercise (goal of >150 min/week). No untoward effects of the lifestyle interventions were observed. In the Diabetes Prevention Program (DPP),32–34 the 3,234 enrolled subjects were slightly younger (mean age 51 years) and more obese (mean BMI 34 kg/m2) but had nearly identical glucose intolerance compared with subjects in the Finnish study. About 45% of the participants were from minority groups (e.g, African-American, Hispanic), and 20% were ≥60 years of age. Subjects were randomized to one of three intervention groups, which included the intensive nutrition and exercise counseling (“lifestyle”) group or either of two masked medication treatment groups: the biguanide metformin group or the placebo group. The latter interventions were combined with standard diet and exercise recommendations. After an average follow-up of 2.8 years (range 1.8–4.6 years), a 58% relative reduction in the progression to diabetes was observed in the lifestyle group (absolute incidence 4.8%), and a 31% relative reduction in the progression of diabetes was observed in the metformin group (absolute incidence 7.8%) compared Position Statement

Improving Diabetes Care in Midwest Community Health Centers With the Health Disparities Collaborative

Abstract: OBJECTIVE —To evaluate the Diabetes Health Disparities Collaborative, an initiative by the Bureau of Primary Health Care to reduce health disparities and improve the quality of diabetes care in community health centers. RESEARCH DESIGN AND METHODS —One year before- after trial. Beginning in 1998, 19 Midwestern health centers undertook a diabetes quality improvement initiative based on a model including rapid Plan-Do-Study-Act cycles from the continuous quality improvement field; a Chronic Care Model emphasizing patient self-management, delivery system redesign, decision support, clinical information systems, leadership, health system organization, and community outreach; and collaborative learning sessions. We reviewed charts of 969 random adults for American Diabetes Association standards, surveyed 79 diabetes quality improvement team members, and performed qualitative interviews. RESULTS —The performance of several key processes of care assessed by chart review increased, including rates of HbA 1c measurement (80–90%; adjusted odds ratio 2.1, 95% CI 1.6–2.8), eye examination referral (36–47%; 1.6, 1.1–2.3), foot examination (40–64%; 2.7, 1.8–4.1), and lipid assessment (55–66%; 1.6, 1.1–2.3). Mean value of HbA 1c tended to improve (8.5–8.3%; difference −0.2, 95% CI −0.4 to 0.03). Over 90% of survey respondents stated that the Diabetes Collaborative was worth the effort and was successful. Major challenges included needing more time and resources, initial difficulty developing computerized patient registries, team and staff turnover, and occasional need for more support by senior management. CONCLUSIONS —The Health Disparities Collaborative improved diabetes care in health centers in 1 year.

The effect of haematopoietic stem cell transplant on papules with 'pebbly' appearance in Hunter's syndrome.

Abstract: Summary Background Hunter's syndrome is associated with several cutaneous findings. For instance, papules with ‘pebbly’ appearance are a specific marker for the disease. However, it remains uncertain whether they disappear after haematopoietic stem cell transplant (HSCT). Objectives To investigate the papules with ‘pebbly’ appearance before and after HSCT in infants with Hunter's syndrome, and to clarify the effect of HSCT on papules. Patients We observed five Japanese boys with Hunter's syndrome who had received HSCT at 4–11 years of age. Results The post-HSCT physical examinations revealed that papules disappeared completely within 35 days after the transplant with progressive reduction of cutaneous tightness in all the patients. Histochemical findings showed that papules contained a large amount of hyaluronic acid in the extracellular materials of the dermis and sulphated acid mucopolysaccharides in dermal fibroblasts before HSCT. Conclusions These results suggest that papules with a ‘pebbly’ appearance fade away through the digestion of a large amount of hyaluronic acid in cutaneous tissues by normal tissue histiocytes or enzymes of donor origin at an early stage after HSCT.

Practical challenges of individualizing diabetes care in older patients.

Abstract: i over the age of 65 represent over 40% of patients with type 2 diabetes. Despite their large numbers, how to best care for this group is uncertain because longitudinal trials of various aspects of diabetes care have not routinely included patients over age 65. In addition to the lack of available trial data, treatment decisions are oftentimes more difficult for older patients because of their clinical heterogeneity. For some older diabetes patients who are relatively healthy and functionally independent, the treatment goals developed for the general population may be appropriate because they are likely to benefit from the preventive therapies for diabetes. In contrast, older diabetes patients who have relatively short life expectancies resulting from significant comorbid conditions may not benefit from standard population goals and may find diabetes-related therapies burdensome.