bluuebunny/crossref_metadata_2025 huggingface dataset:
Race, Ethnicity, Socioeconomic Position, and Quality of Care for Adults With Diabetes Enrolled in Managed Care
Authors: Brown Arleen F. , Gregg Edward W. , Stevens Mark R. , Karter Andrew J. , Weinberger Morris , Safford Monika M. , Gary Tiffany L. , Caputo Dorothy A. , Waitzfelder Beth , Kim Catherine , Beckles Gloria L.
Published: March 2007

OBJECTIVE—To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings.

RESEARCH DESIGN AND METHODS—We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA1c [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control).

RESULTS—Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP.

CONCLUSIONS—In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.
The Effect of Monochromatic Infrared Energy on Sensation in Patients With Diabetic Peripheral Neuropathy
Authors: Clifft Judy K. , Kasser Richard J. , Newton Timothy S. , Bush Andrew J.
Published: March 2007

OBJECTIVE—The purpose of this study was to determine the effect of monochromatic infrared energy (MIRE) on plantar sensation in subjects with diabetic peripheral neuropathy.

RESEARCH DESIGN AND METHODS—In this randomized, double-blind, placebo-controlled study, 39 subjects with diabetic peripheral neuropathy completed the 8-week study. Subjects received 30 min of active or placebo MIRE three times a week for 4 weeks. Plantar sensation was tested with monofilaments at the beginning of the study (M1), following 4 weeks of treatment (M2), and after an additional 4 weeks of nontreatment (M3). The number of sites that could sense the 5.07 monofilament was totaled at M1, M2, and M3. Data were analyzed using a special repeated-measures statistic followed by a post hoc Tukey-Kramer test.

RESULTS—The average number of sites that patients could sense the 5.07 monofilament increased for both the active and placebo groups. There were significant gains from M1 to M2 (P < 0.002), no significant gains from M2 to M3 (P = 0.234), and significant gains from M1 to M3 (P < 0.002) for both the active and placebo groups. There were no significant differences between active and placebo groups at any measurement.

CONCLUSIONS—Thirty minutes of active MIRE applied 3 days per week for 4 weeks was no more effective than placebo MIRE in increasing sensation in subjects with diabetic peripheral neuropathy. Clinicians should be aware that MIRE may not be an effective modality for improving sensory impairments in patients with diabetic neuropathy.
Dietary Calcium, Vitamin D, and the Prevalence of Metabolic Syndrome in Middle-Aged and Older U.S. Women
Authors: Liu Simin , Song Yiqing , Ford Earl S. , Manson JoAnn E. , Buring Julie E. , Ridker Paul M.
Published: March 2007

OBJECTIVE—To examine whether and to what extent intakes of calcium and vitamin D are related to the metabolic syndrome in middle-aged or older women.

RESEARCH DESIGN AND METHODS—We analyzed data from 10,066 women aged ≥45 years participating in the Women’s Health Study who were free of cardiovascular disease, cancer, or diabetes and who never used postmenopausal hormones. We used multiple logistic regression models to estimate multivariable odds ratios (ORs) and 95% CIs comparing different dietary intake levels of calcium and vitamin D.

RESULTS—In age- and calorie-adjusted analyses, higher intakes of total, dietary, and supplemental calcium were significantly and inversely associated with the prevalence of metabolic syndrome. After further adjusting for smoking status, exercise, alcohol intake, multivitamin use, and parental history of myocardial infarction before age 60 years, the ORs of having the metabolic syndrome for increasing quintiles of total calcium intake were 1.00 (reference), 0.82 (95% CI 0.70–0.97), 0.84 (0.71–0.99), 0.70 (0.59–0.83), and 0.64 (0.54–0.77) (P for trend <0.0001). This association was not appreciably altered by additional adjustment for other dietary factors or total vitamin D intake. In contrast, neither total (P for trend = 0.13) nor supplemental (P for trend = 0.45) vitamin D was significantly associated with metabolic syndrome. Dietary vitamin D was inversely associated with prevalence of metabolic syndrome but was not independent of total calcium intake. Similar strong relations between intakes of dairy products and metabolic syndrome were also observed. After adjustment for lifestyle and dietary factors, the multivariable ORs comparing highest with lowest intake categories were 0.66 (0.55–0.80) (P for trend <0.0001) for total dairy products and 0.85 (0.71–1.02) (P for trend = 0.05) for total milk intake.

CONCLUSIONS—Our results indicate that intakes of calcium and dairy products may be associated with lower prevalence of the metabolic syndrome in middle-aged and older women.
Hypertension Prevalence, Awareness, Treatment, and Control in an Adult Type 1 Diabetes Population and a Comparable General Population
Authors: Maahs David M. , Kinney Gregory L. , Wadwa Paul , Snell-Bergeon Janet K. , Dabelea Dana , Hokanson John , Ehrlich James , Garg Satish , Eckel Robert H. , Rewers Marian J.
Published: March 2007

OBJECTIVE—To compare the prevalence, awareness, treatment, and control of hypertension in a population-representative sample of adults with type 1 diabetes and comparable nondiabetic control subjects.

RESEARCH DESIGN AND METHODS—In 2000–2002, the Coronary Artery Calcification in Type 1 Diabetes Study enrolled 1,416 individuals aged 19–56 years with no known history of coronary artery disease: 652 type 1 diabetic patients (46% male, mean age 37 years) and 764 nondiabetic control subjects (50% male, mean age 39 years). Subjects were asked if they had been told by a physician that they had hypertension or were on a blood pressure medication. Blood pressure was measured using standardized Joint National Committee (JNC) protocol.

RESULTS—Type 1 diabetic subjects, compared with nondiabetic subjects, had higher rates of hypertension prevalence (43 vs. 15%, P < 0.001), awareness (53 vs. 45%, P = 0.11), treatment (87 vs. 47%, P < 0.001), and control (55 vs. 32%, P < 0.001) for the JNC 6 goal (130/85 mmHg). Only 42% of all type 1 diabetic hypertensive subjects met the new JNC 7 goal (130/80 mmHg). Type 1 diabetic subjects had better blood pressure control (72 vs. 32%, P < 0.0001), using 140/90 mmHg as a common measure. The majority of treated subjects were on a single antihypertensive agent (75 vs. 64%).

CONCLUSIONS—Subjects with type 1 diabetes have higher rates of hypertension prevalence, treatment, and control than nondiabetic subjects. However, hypertension remains largely uncontrolled, even if treated in high-risk populations, such as type 1 diabetic subjects and undiagnosed individuals in the general population. Achieving more stringent blood pressure goals will require increased attention and may necessitate the use of multiple antihypertensive agents.
Poor Pregnancy Outcome in Women With Type 2 Diabetes
Authors: Clausen Tine D. , Mathiesen Elisabeth , Ekbom Pia , Hellmuth Ellinor , Mandrup-Poulsen Thomas , Damm Peter
Published: March 2007

OBJECTIVE— To evaluate the perinatal outcome and the frequency of maternal complications in pregnancies of women with type 2 diabetes during 1996–2001.

RESEARCH DESIGN AND METHODS— Medical records of 61 consecutive singleton pregnancies in women with type 2 diabetes from 1996 to 2001 were studied. Pregnancy outcome was compared with that of pregnant women with type 1 diabetes during 1996–2000, the background population, and pregnant women with type 2 diabetes during 1980–1992 from the same department.

RESULTS— The perinatal mortality in pregnancies complicated by type 2 diabetes (4/61, 6.6%) was increased four- and ninefold, respectively, and the rate of major congenital malformations (4/60, 6.7%) was more than doubled, although not statistically significant, compared with type 1 diabetic pregnancies and the background population. The glycemic control was similar or better in women with type 2 diabetes compared with women with type 1 diabetes. Multivariate logistic regression analysis in the pooled group of pregnancies with pregestational diabetes from 1996 to 2001 showed that high HbA1c at admission and type 2 diabetes were independently associated with a serious adverse fetal outcome (perinatal mortality and/or major congenital malformations). The perinatal mortality and the rate of major congenital malformations in type 2 diabetic pregnancies have increased during the last decade.

CONCLUSIONS— The perinatal outcome of pregnancies in women with type 2 diabetes during 1996–2001 is poor. It is worse than the outcome of pregnancies in women with type 1 diabetes and the background population in the same period, as well as in women with type 2 diabetes studied during 1982–1990.
β-Score
Authors: Ryan Edmond A. , Paty Breay W. , Senior Peter A. , Lakey Jonathan R.T. , Bigam David , Shapiro A.M. James
Published: March 2007

OBJECTIVE—Success after islet transplantation can be defined in terms of insulin independence, C-peptide secretion, or glycemic control. These measures are interdependent and all need to be considered in evaluating β-cell function after islet transplantation. For the current study, a composite β-score was developed that provides an integrated measure of β-cell function success after islet transplantation.

RESEARCH DESIGN AND METHODS—The proposed scoring system gave 2 points each for normal fasting glucose, HbA1c, stimulated C-peptide, and absence of insulin or oral hypoglycemic agent use. No points were awarded if the fasting glucose was in the diabetic range, the HbA1c was >6.9%, C-peptide secretion was absent on stimulation, or daily insulin use was in excess of 0.24 units/kg. One point was given for intermediate values. The score ranged from 0 to 8 and was correlated with the glucose value 90 min after a standard mixed meal challenge (n = 218) in 57 subjects before and after islet transplantation. The score was also used to follow subjects for up to 5 years after islet transplantation.

RESULTS—The β-score correlated well with the plasma glucose level 90 min after a mixed meal challenge (r = −0.849, P < 0.001). On follow-up, the β-score rose after the first transplant and was maintained up to 5 years, demonstrating continuing function of the transplanted β-cells.

CONCLUSIONS—The β-score provides a simple clinical scoring system that encompasses glycemic control, diabetes therapy, and endogenous insulin secretion that correlates well with physiological measures of β-cell function. On this basis, it is suitable as an overall measure of β-cell transplant function. The β-score gives an integrated measure of β-cell function as a continuum that may be more useful than simply assessing the presence or absence of insulin independence.
Chronic Vascular Inflammation in Patients With Type 2 Diabetes
Authors: Feng Lei , Matsumoto Carolyn , Schwartz Allan , Schmidt Ann Marie , Stern David M. , Pile-Spellman John
Published: March 2007

OBJECTIVE—Chronic vascular inflammation may play a role in the development of macrovascular complications in diabetic patients. In this study, we examine the association of endothelial expression of two inflammatory mediators, receptor for advanced glycation end product (RAGE) and monocyte chemoattractant protein-1 (MCP-1), with type 2 diabetes using novel endothelial biopsy and RT-PCR techniques.

RESEARCH DESIGN AND METHODS—Endothelial samples are obtained from the aorta of 12 patients with type 2 diabetes and 23 control subjects who underwent cardiac catheterization for chest pain syndrome or heart transplant follow-up. Endothelial cells are purified using magnetic beads with adsorbed CD146 antibody and subjected to RT-PCR analysis of RAGE and MCP-1 transcripts. The association of RAGE and MCP-1 expression with type 2 diabetes is assessed with χ2 test and confirmed with in vitro experiments on human aorta endothelial cells.

RESULTS—RT-PCR reveals gene expression patterns in patient-derived endothelial cells. Strong associations are observed between induction of RAGE mRNA and diabetes (P < 0.01) and between induction of RAGE and MCP-1 transcripts (P < 0.05). Treatment of cultured human aortic endothelial cells with S100b induces the expression of MCP-1 and RAGE transcripts.

CONCLUSIONS—Endothelial cells can be harvested during cardiac catheterization and can be characterized with respect to molecular phenotypes under the influence of both genetic and environmental factors. Induction of RAGE and MCP-1 transcripts in patients with diabetes supports a role of chronic vascular inflammation in macrovascular complications.
Are Granulocyte Colony–Stimulating Factors Beneficial in Treating Diabetic Foot Infections?
Authors: Cruciani Mario , Lipsky Benjamin A. , Mengoli Carlo , de Lalla Fausto
Published: March 2007

OBJECTIVE—To assess the value of granulocyte colony–stimulating factor (G-CSF) as adjunctive therapy for diabetic foot infections.

RESEARCH DESIGN AND METHODS—We systematically searched the medical literature (including Medline, Embase, LookSmart, and the Cochrane Library) for prospective randomized studies that used G-CSF as an adjunct to standard treatment for diabetic foot infections. Using a conventional meta-analysis, we pooled the relative risks (RRs) for outcomes of interest, including resolution of infection, wound healing, duration of antibiotic therapy, and need for various surgical interventions, using a fixed-effects model.

RESULTS—Five randomized trials, with a total of 167 patients, met our inclusion criteria. The methodological quality of the studies was satisfactory. The investigators administered various G-CSF preparations parenterally for between 3 and 21 days. The meta-analysis revealed that adding G-CSF did not significantly affect the resolution of infection or the healing of the wounds but was associated with a significantly reduced likelihood of lower extremity surgical interventions (RR 0.38 [95% CI 0.20–0.69], number of patients who needed to be treated: 4.5), including amputation (0.41 [0.17–0.95], number of patients who needed to be treated: 8.6). There was no evidence of heterogeneity among the studies or of publication bias, suggesting that these conclusions are reasonably generalizable and robust.

CONCLUSIONS—Adjunctive G-CSF treatment does not appear to hasten the clinical resolution of diabetic foot infection or ulceration but is associated with a reduced rate of amputation and other surgical procedures. The small number of patients who needed to be treated to gain these benefits suggests that using G-CSF should be considered, especially in patients with limb-threatening infections.
The Case for Biennial Retinopathy Screening in Children and Adolescents
Authors: Maguire Ann , Chan Albert , Cusumano Janine , Hing Stephen , Craig Maria , Silink Martin , Howard Neville , Donaghue Kim
Published: March 2007

OBJECTIVE—Current guidelines recommend annual retinopathy screening 2 years after onset (for pubertal-onset type 1 diabetes) and after 5 years (or age 11, whichever is earlier) for prepubertal onset. Our aim was to describe the natural history of retinopathy and to explore optimal retinal screening intervals for children and adolescents (aged <20 years) screened according to these guidelines.

RESEARCH DESIGN AND METHODS—More than 1,000 children and adolescents, followed longitudinally, were screened for retinopathy using seven-field stereoscopic fundus photography through dilated pupils. Of these, 668 had baseline and follow-up retinal screening. Using generalized estimating equations, we compared the risk of retinopathy with baselines at yearly intervals, in older and younger groups, in higher risk groups (diabetes duration >10 years or HbA1c >10% at any screening), and after stratification ≤10 and <10 years in duration.

RESULTS—After 1 year, retinopathy did not increase significantly in the older group (n = 618, median HbA1c 8.7%, range 8.0–9.5), younger group (n = 50, median HbA1c 8.5%, range 8.0–9.2), or the higher-risk groups. Retinopathy increased significantly after 2 years in the older group (P = 0.003) but not until 6 years in the younger group (P = 0.01). In the group with HbA1c >10% recorded at any visit, retinopathy increased significantly after 2 years (P = 0.001) but not until 3 years in the group whose HbA1c was always ≤10% (P = 0.003). After the second eye assessment, retinopathy did not increase significantly until 3 and 6 years later in the older and younger groups, respectively (P = 0.028 and 0.014).

CONCLUSIONS—These results suggest that adolescents (in reasonable metabolic control) could safely be screened every 2 years rather than the currently recommended 1-year interval. In younger children, the next screening interval could be >2 years later. Individuals with especially poor control, duration >10 years, or significant retinopathy should be screened more frequently.
Associations of Mortality and Diabetes Complications in Patients With Type 1 and Type 2 Diabetes
Authors: Cusick Michael , Meleth Annal D. , Agrón Elvira , Fisher Marion R. , Reed George F. , Knatterud Genell L. , Barton Franca B. , Davis Matthew D. , Ferris Frederick L. , Chew Emily Y. ,   Early Treatment Diabetic Retinopathy Study (ETDRS) Research Group
Published: March 2007

OBJECTIVE—Diabetes is a leading cause of morbidity and mortality. The purpose of this study is to assess the associations between diabetes complications and mortality in the Early Treatment Diabetic Retinopathy Study (ETDRS).

RESEARCH DESIGN AND METHODS—We examined demographic, clinical, and laboratory characteristics of the 3,711 subjects enrolled in the ETDRS, a randomized controlled clinical trial designed to evaluate the role of laser photocoagulation and aspirin therapy for diabetic retinopathy. The outcome assessed was all-cause mortality. Multivariable Cox proportional hazards regression was used to assess associations between diabetes complications and mortality for type 1 and type 2 diabetes separately.

RESULTS—The 5-year estimates of all-cause mortality were 5.5 and 18.9% for patients with type 1 and type 2 diabetes, respectively. In patients with type 1 diabetes, amputation (hazard ratio [HR] 5.08 [95% CI 2.06–12.54]) and poor visual acuity (1.74 [1.10–2.75]) remained significantly associated with mortality, after adjusting for other diabetes complications and baseline characteristics. In patients with type 2 diabetes, macrovascular disease and worsening levels of nephropathy, neuropathy, retinopathy, and visual acuity are associated with progressively increasing risks of mortality, after controlling for other baseline risk factors.

CONCLUSIONS—Amputation is the strongest predictor for mortality in patients with type 1 diabetes. All complications independently predict mortality in patients with type 2 diabetes. There is an increased risk for mortality as the degree of each complication worsens. Additional studies are needed to investigate the effectiveness of tertiary prevention to decrease mortality in these patients.
Cardiovascular Disease in U.S. Patients With Metabolic Syndrome, Diabetes, and Elevated C-Reactive Protein
Authors: Malik Shaista , Wong Nathan D. , Franklin Stanley , Pio Jose , Fairchild Carol , Chen Roland
Published: March 2007

OBJECTIVE—C-reactive protein (CRP) independently predicts cardiovascular disease (CVD); whether it can stratify risk in those with metabolic syndrome and diabetes is not well documented. We evaluated whether elevated CRP levels modify the relationship of metabolic syndrome and diabetes with CVD in U.S. adults.

RESEARCH DESIGN AND METHODS—In a cross-sectional study of 3,873 subjects (weighted to 156 million) aged ≥18 years participating in the National Health and Nutrition Examination Survey 1999–2000, subjects were classified as having diabetes, metabolic syndrome according to modified National Cholesterol Education Program criteria, or neither condition by low (<1 mg/l), intermediate (1–3 mg/l), or high (>3 mg/l) CRP levels. Logistic regression examined the odds of CVD by disease condition and CRP group.

RESULTS—After adjusting for age, sex, smoking, and total cholesterol, compared with those with neither metabolic syndrome nor diabetes and low CRP levels, the odds of CVD were 1.99 (95% CI 1.10–3.59) for those with no disease and high CRP levels and 2.67 (1.30–5.48) for those with metabolic syndrome and intermediate CRP. Persons with metabolic syndrome but high CRP had an odds ratio (OR) of 3.33 (1.80–6.16), similar to those with diabetes and low CRP (3.21 [1.27–8.09]). The likelihood of CVD was highest in those with diabetes who had intermediate CRP levels (6.01 [2.54–14.20]) and in those with diabetes and high CRP (7.73 [3.99–14.95]).

CONCLUSIONS—In this cross-sectional analysis, CVD is more common in those with metabolic syndrome or diabetes who have elevated CRP. Stratification by CRP may add prognostic information in patients with metabolic syndrome or diabetes.
A Systematic Review of Drug Therapy to Delay or Prevent Type 2 Diabetes
Authors: Padwal Raj , Majumdar Sumit R. , Johnson Jeff A. , Varney Janice , McAlister Finlay A.
Published: March 2007

OBJECTIVE—To systematically review the evidence for the prevention of type 2 diabetes by pharmacological therapies.

RESEARCH DESIGN AND METHODS—Randomized controlled trials and cohort studies examining the effect of oral hypoglycemic agents, antiobesity agents, antihypertensive agents, statins, fibrates, and estrogen on the incidence of type 2 diabetes were identified from MEDLINE, EMBASE, the Cochrane Controlled Trials Registry, and searches of reference lists. Two reviewers independently assessed studies for inclusion and performed data extraction.

RESULTS—Ten studies of oral hypoglycemic agents and 15 studies of nonoral hypoglycemic agents were found. Oral hypoglycemic agents and orlistat are the only drugs that have been studied in randomized controlled trials with diabetes incidence as the primary end point. In the largest studies of 2.5–4.0 years’ duration, metformin (relative risk [RR] 0.69, 95% CI 0.57–0.83), acarbose (0.75, 0.63–0.90), troglitazone (0.45, 0.25–0.83), and orlistat (hazard ratio [HR] 0.63, 95% CI 0.46–0.86) have all been shown to decrease diabetes incidence compared with placebo; however, follow-up rates varied from 43 to 96%. Current evidence for statins, fibrates, antihypertensive agents, and estrogen is inconclusive. In addition, the critical question of whether drugs are preventing, or simply delaying, onset of diabetes remains unresolved.

CONCLUSIONS—Currently, no single agent can be definitively recommended for diabetes prevention. Future studies should be designed with diabetes incidence as the primary outcome and should be of sufficient duration to differentiate between genuine diabetes prevention as opposed to simple delay or masking of this condition.
The Relationship Between Knowledge of Recent HbA1c Values and Diabetes Care Understanding and Self-Management
Authors: Heisler Michele , Piette John D. , Spencer Michael , Kieffer Edie , Vijan Sandeep
Published: March 2007

OBJECTIVE—Knowledge of one’s actual and target health outcomes (such as HbA1c values) is hypothesized to be a prerequisite for effective patient involvement in managing chronic diseases such as diabetes. We examined 1) the frequency and correlates of knowing one’s most recent HbA1c test result and 2) whether knowing one’s HbA1c value is associated with a more accurate assessment of diabetes control and better diabetes self-care understanding, self-efficacy, and behaviors related to glycemic control.

RESEARCH DESIGN AND METHODS—We conducted a cross-sectional survey of a sample of 686 U.S. adults with type 2 diabetes in five health systems who had HbA1c checked in the previous 6 months. Independent variables included patient characteristics, health care provider communication, and health system type. We examined bivariate and multivariate associations between each variable and the respondents’ knowledge of their last HbA1c values and assessed whether knowledge of HbA1c was associated with key diabetes care attitudes and behaviors.

RESULTS—Of the respondents, 66% reported that they did not know their last HbA1c value and only 25% accurately reported that value. In multivariate analyses, more years of formal education and high evaluations of provider thoroughness of communication were independently associated with HbA1c knowledge. Respondents who knew their last HbA1c value had higher odds of accurately assessing their diabetes control (adjusted odds ratio 1.59, 95% CI 1.05–2.42) and better reported understanding of their diabetes care (P < 0.001). HbA1c knowledge was not associated with respondents’ diabetes care self-efficacy or reported self-management behaviors.

CONCLUSIONS—Respondents who knew their HbA1c values reported better diabetes care understanding and assessment of their glycemic control than those who did not. Knowledge of one’s HbA1c level alone, however, was not sufficient to translate increased understanding of diabetes care into the increased confidence and motivation necessary to improve patients’ diabetes self-management. Strategies to provide information to patients must be combined with other behavioral strategies to motivate and help patients effectively manage their diabetes.
Prevalence and Correlates of Depressive Symptoms Among Rural Older African Americans, Native Americans, and Whites With Diabetes
Authors: Bell Ronny A. , Smith Shannon L. , Arcury Thomas A. , Snively Beverly M. , Stafford Jeanette M. , Quandt Sara A.
Published: March 2007

OBJECTIVE—Depression is associated with morbidity, mortality, and decreased quality of life and is a well-established complication among people with diabetes. Little is known about the prevalence and correlates of depressive symptoms among older adults living in rural communities, particularly among ethnic minority groups, who are at increased risk of developing diabetes and complications.

RESEARCH DESIGN AND METHODS—Data were analyzed from the ELDER (Evaluating Long-term Diabetes Self-management Among Elder Rural Adults) diabetes study in which face-to-face interviews were conducted with 696 older (≥65 years of age) African-American, Native American, and white men and women in two rural counties in central North Carolina.

RESULTS—Using a criterion of ≥9 on a modified CES-D (Center for Epidemiologic Study of Depression) scale, 15.8% of the sample had depressive symptoms. In bivariate analyses, depressive symptomatology was more common among women and individuals who were unmarried and had less than a high school education, fewer financial resources, more chronic conditions, more prescription medications, and lower physical functioning. In multivariate analyses, sex, education, living arrangement, BMI, number of prescription medications, number of chronic conditions, and physical functioning remained significant.

CONCLUSIONS—These results show that older rural adults with diabetes are at high risk for depressive symptoms, regardless of their ethnic group, and that certain demographic and health characteristics are important factors in this association. These findings add to the limited body of knowledge of comorbid depression in this population. Greater attention should be paid to diagnosing and treating this condition by those who provide care to these populations.
Depression Symptoms and Antidepressant Medicine Use in Diabetes Prevention Program Participants
Authors:   The Diabetes Prevention Program Research Group
Published: March 2007

OBJECTIVE—To assess depression markers (symptoms and antidepressant medicine use) in Diabetes Prevention Program (DPP) participants and to determine whether changes in depression markers during the course of the study were associated with treatment arm, weight change, physical activity level, or participant demographic characteristics.

RESEARCH DESIGN AND METHODS—DPP participants (n = 3,187) in three treatment arms (intensive lifestyle, metformin, and placebo) completed the Beck Depression Inventory (BDI) and reported on use of antidepressant medicines at randomization and subsequently at each annual visit (average duration in study 3.2 years).

RESULTS—On study entry, 10.3% of participants had BDI scores ≥11, which was used as a threshold for mild depression, 5.7% took antidepressant medicines, and 0.9% had both depression markers. During the DPP, the proportion of participants with elevated BDI scores declined (from 10.3% at baseline to 8.4% at year 3), while the proportion taking antidepressant medicines increased (from 5.7% at baseline to 8.7% at year 3), leaving the proportion with either marker unchanged. These time trends were not significantly associated with the DPP treatment arm. Depression markers throughout the study were associated with some participant demographic factors, adjusted for other factors. Men were less likely to have elevated depression scores and less likely to use antidepressant medicine at baseline (9.0% of men and 17.9% of women had at least one marker of depression) and throughout the study (P <0.0001). Those with more education were less likely to have elevated symptom scores (P = 0.0007) but more likely to be taking antidepressant medicine (P = 0.002). Non-Hispanic white participants were less likely than African Americans to have BDI scores ≥11 (P = 0.03), but white participants were more likely to be taking antidepressant medicine than any other racial/ethnic group (P <0.0001).

CONCLUSIONS—DPP participation was not associated with changes in levels of depression. Countervailing trends in the proportion of DPP participants with elevated depression symptoms and the proportion taking antidepressant medicine resulted in no significant change in the proportion with either marker. The finding that those taking antidepressant medicine often do not have elevated depression symptoms indicates the value of assessing both markers when estimating overall depression rates.
Coronary Artery Disease Is Common in Nonuremic, Asymptomatic Type 1 Diabetic Islet Transplant Candidates
Authors: Senior Peter A. , Welsh Robert C. , McDonald Charlotte G. , Paty Breay W. , Shapiro A.M. James , Ryan Edmond A.
Published: March 2007

OBJECTIVE—Coronary artery disease (CAD) is the most common cause of death in patients with type 1 diabetes. Asymptomatic CAD is common in uremic diabetic patients, but its prevalence in nonuremic type 1 diabetic patients is unknown. The prevalence of CAD was determined by coronary angiography and the performance of noninvasive cardiac investigation evaluated in type 1 diabetic islet transplant (ITX) candidates with preserved renal function.

RESEARCH DESIGN AND METHODS—A total of 60 consecutive type 1 diabetic ITX candidates (average age 46 years [mean 24–64], 23 men, and 47% ever smokers) underwent coronary angiography, electrocardiographic stress testing (EST), and myocardial perfusion imaging (MPI) in a prospective cohort study. CAD was indicated on angiography by the presence of stenoses >50%. Models to predict CAD were examined by logistic regression.

RESULTS—Most subjects (53 of 60) had no history or symptoms of CAD; 23 (43%) of these asymptomatic subjects had stenoses >50%. CAD was associated with age, duration of diabetes, hypertension, and smoking. Although specific, EST and MPI were not sensitive as predictors of CAD on angiography (specificity 0.97 and 0.93, sensitivity 0.17 and 0.04, respectively) but helped identify two of three subjects requiring revascularization. EST and MPI did not enhance logistic regression models. A clinical algorithm to identify low-risk subjects who may not require angiography was highly sensitive but was applicable only to a minority (n = 8, sensitivity 1.0, specificity 0.27, negative predictive value 1.0).

CONCLUSIONS—Nonuremic type 1 diabetic patients with hypoglycemic unawareness and/or metabolic lability referred for ITX are at high risk for asymptomatic CAD despite negative noninvasive investigations. Aggressive management of cardiovascular risk factors and further investigation into optimal cardiac risk stratification in type 1 diabetes are warranted.
Impact of Intensive Lifestyle and Metformin Therapy on Cardiovascular Disease Risk Factors in the Diabetes Prevention Program
Authors:   The Diabetes Prevention Program Research Group
Published: March 2007

OBJECTIVE—The Diabetes Prevention Program demonstrated the ability to delay or prevent type 2 diabetes in participants with impaired glucose tolerance (IGT). Participants with IGT are at high risk for cardiovascular disease (CVD), with a marked increase in the number and severity of CVD risk factors. We prospectively assessed the impact of our interventions on hypertension, dyslipidemia, and CVD events.

RESEARCH DESIGN AND METHODS—The study group consisted of 3,234 individuals with IGT randomly assigned to receive intensive lifestyle intervention, metformin, or placebo. Annual assessment of blood pressure, lipids, electrocardiogram, and CVD events was undertaken.

RESULTS—Hypertension was present in 30% of participants at study entry and then increased in the placebo and metformin groups, although it significantly decreased with intensive lifestyle intervention. Triglyceride levels fell in all treatment groups, but fell significantly more with intensive lifestyle intervention. Total cholesterol and LDL cholesterol levels were similar among treatment groups. Intensive lifestyle intervention significantly increased the HDL cholesterol level and reduced the cumulative incidence of the proatherogenic LDL phenotype B. At 3 years of follow-up, the use for pharmacologic therapy to achieve established goals in the intensive lifestyle group was 27–28% less for hypertension and 25% less for hyperlipidemia compared with placebo and metformin groups. Over an average of 3 years, 89 CVD events from 64 participants were positively adjudicated studywide, with no differences among treatment groups.

CONCLUSIONS—Lifestyle intervention improves CVD risk factor status compared with placebo and metformin therapy. Although no differences in CVD events were noted after 3 years, achieved risk factor modifications suggest that longer intervention may reduce CVD event rates.
Predictors of Changes in Glucose Tolerance Status in Obese Youth
Authors: Weiss Ram , Taksali Sara E. , Tamborlane William V. , Burgert Tania S. , Savoye Mary , Caprio Sonia
Published: March 2007

OBJECTIVE—Type 2 diabetes in obese youth is an emerging problem. The metabolic and anthropometric predictors of change in glucose tolerance status in obese youth are unknown.

RESEARCH DESIGN AND METHODS—A total of 117 obese children and adolescents were studied by performing an oral glucose tolerance test (OGTT) at baseline and after ∼2 years. Data from both OGTTs and changes in weight were examined to identify youth at highest risk for developing diabetes and the factors that have the strongest impact on glucose tolerance.

RESULTS—Eighty-four subjects had normal glucose tolerance (NGT) and 33 impaired glucose tolerance (IGT) at baseline. Eight subjects (all of whom had IGT at baseline) developed type 2 diabetes, whereas 15 subjects with IGT reverted to NGT. In this cohort, severe obesity, impaired glucose tolerance, and African-American background emerged as the best predictors of developing type 2 diabetes, whereas fasting glucose, insulin, and C-peptide were nonpredictive. Changes in insulin sensitivity, strongly related to weight change, had a significant impact on the 2-h glucose level on the follow-up study.

CONCLUSIONS—Severely obese children and adolescents with IGT, particularly of African-American descent, are at very high risk for developing type 2 diabetes over a short period of time. Parameters derived from an OGTT and not fasting samples can serve as predictors of changes in glucose tolerance.
The Challenge of Achieving National Cholesterol Goals in Patients With Diabetes
Authors: Kennedy Amanda G. , MacLean Charles D. , Littenberg Benjamin , Ades Philip A. , Pinckney Richard G.
Published: March 2007

OBJECTIVE—This study analyzed lipid results from a large community-based population of patients with diabetes to assess the feasibility of attaining the standard and new optional LDL-based lipid goals using currently available lipid-lowering medications.

RESEARCH DESIGN AND METHODS—Ambulatory patients with diabetes who were interviewed as part of the Vermont Diabetes Information System trial with a reported LDL were analyzed. Patients were categorized into high-risk and very-high-risk cardiovascular status. For patients not at the LDL goal, the required changes in therapy to achieve the goal were assessed.

RESULTS—Of the entire cohort, 49.4% (321 of 650) had LDL <100 mg/dl. According to the National Cholesterol Education Program, 29.4% (191 of 650) of patients were very high risk and have an optional LDL goal of <70 mg/dl. Only 15.7% (30 of 191) of very-high-risk patients had an LDL <70 mg/dl. Based on our analysis of high-risk patients, 17 of 459 (3.7%) would require more than two lipid-lowering drugs to achieve an LDL <100 mg/dl. In the very-high-risk group, we estimate that 26.2% (50 of 191) of patients will not reach LDL <70 mg/dl with two lipid-lowering medications.

CONCLUSIONS—In many patients with diabetes and cardiovascular disease, it will be difficult to attain an LDL goal of <70 mg/dl. Approximately 25% of patients will require more than two lipid-lowering drugs at maximal doses to attain this goal, assuming 100% tolerance of lipid-lowering medications.
One-Hour Postload Plasma Glucose in Middle Age and Medicare Expenditures in Older Age Among Nondiabetic Men and Women
Authors: Liu Kiang , Dyer Alan R. , Vu Thanh-Huyen , Pirzada Amber , Manheim Larry M. , Manning Willard G. , Ashraf Muhammad S. , Garside Daniel B. , Daviglus Martha L.
Published: March 2007

OBJECTIVE—To examine associations in nondiabetic individuals of 1-h postload plasma glucose measured in young adulthood and middle age with subsequent Medicare expenditures for cardiovascular disease (CVD), diabetes, cancer, and all health care at age 65 years or older using data from the Chicago Heart Association Detection Project in Industry (CHA).

RESEARCH DESIGN AND METHODS—Medicare data (1984–2000) were linked with CHA baseline records (1967–1973) for 8,580 men and 6,723 women ages 33–64 years who were free of coronary heart disease, diabetes, and major electrocardiogram (ECG) abnormalities and who were Medicare eligible (65+ years) for at least 2 years. Participants were classified based on 1-h postload plasma glucose levels <120, 120–199, or ≥200 mg/dl.

RESULTS—With adjustment for baseline age, cigarette smoking, serum cholesterol, systolic blood pressure, BMI, ethnicity, education, and minor ECG abnormalities, the average annual and cumulative Medicare, total, and diabetes- and CVD-related charges were significantly higher with higher baseline plasma glucose in women, while only diabetes-related charges were significantly higher in men. For example, in women, multivariate-adjusted CVD-related cumulative charges were, respectively, $14,260, $18,909, and $21,183 for the three postload plasma glucose categories (P value for trend = 0.035).

CONCLUSIONS—These findings suggest that maintaining low glucose levels early in life has the potential to reduce health care costs in older age.
A Randomized Multicenter Trial Comparing the GlucoWatch Biographer With Standard Glucose Monitoring in Children With Type 1 Diabetes
Authors:   The Diabetes Research in Children Network (DirecNet) Study Group
Published: March 2007

OBJECTIVE—This study assesses whether use of the GlucoWatch G2 Biographer (GW2B) in addition to standard glucose monitoring lowers HbA1c and reduces hypoglycemia compared with standard glucose monitoring alone.

RESEARCH DESIGN AND METHODS—In all, 200 subjects aged 7 to <18 years with type 1 diabetes were randomly assigned at five centers to standard glucose monitoring (usual care) or standard glucose monitoring plus GW2B use for 6 months. Study outcomes included HbA1c values obtained at 6 months and occurrence of severe hypoglycemia.

RESULTS—The mean HbA1c at baseline was 8.0% in both groups; at 6 months, HbA1c was 7.9% in the usual care group and 8.1% in the GW2B group (95% CI for mean reduction in the GW2B group compared with the usual care group −0.4 to 0.1%; P = 0.15). A decrease in HbA1c of ≥0.5% was achieved in 21% of the usual care group and 28% of the GW2B group (P = 0.29). Severe hypoglycemia events occurred in 7% of the GW2B group and in 2% of the usual care group (P = 0.10). In the GW2B group, sensor use declined throughout the study from a mean value of 2.1 times/week in the 1st month to 1.5 times/week in the 6th month. Reasons given for declining use included skin irritation (76%), frequent skips (56%), excessive alarms (47%), and inaccurate readings (33%).

CONCLUSIONS—Use of the GW2B in addition to standard glucose monitoring did not improve glycemic control or reduce the frequency of severe hypoglycemia. Skin reactions and other problems led to decreasing sensor use over time.
Role of the Decrement in Intraislet Insulin for the Glucagon Response to Hypoglycemia in Humans
Authors: Gosmanov Niyaz R. , Szoke Ervin , Israelian Zarmen , Smith Tamar , Cryer Philip E. , Gerich John E. , Meyer Christian
Published: March 2007

OBJECTIVE—Animal and in vitro studies indicate that a decrease in β-cell insulin secretion, and thus a decrease in tonic α-cell inhibition by intraislet insulin, may be an important factor for the increase in glucagon secretion during hypoglycemia. However, in humans this role of decreased intraislet insulin is still unclear.

RESEARCH DESIGN AND METHODS—We studied glucagon responses to hypoglycemia in 14 nondiabetic subjects on two separate occasions. On both occasions, insulin was infused from 0 to 120 min to induce hypoglycemia. On one occasion, somatostatin was infused from −60 to 60 min to suppress insulin secretion, so that the decrement in intraislet insulin during the final 60 min of hypoglycemia would be reduced. On the other occasion, subjects received an infusion of normal saline instead of the somatostatin.

RESULTS—During the 2nd h of the insulin infusion, when somatostatin or saline was no longer being infused, plasma glucose (∼2.6 mmol/l) and insulin levels (∼570 pmol/l) were comparable in both sets of experiments (both P > 0.4). In the saline experiments, insulin secretion remained unchanged from baseline (−90 to −60 min) before insulin infusion and decreased from 1.20 ± 0.12 to 0.16 ± 0.04 pmol · kg−1 · min−1 during insulin infusion (P < 0.001). However, in the somatostatin experiments, insulin secretion decreased from 1.18 ± 0.12 pmol · kg−1 · min−1 at baseline to 0.25 ± 0.09 pmol · kg−1 · min−1 before insulin infusion so that it did not decrease further during insulin infusion (−0.12 ± 0.10 pmol · kg−1 · min−1, P = 0.26) indicating the complete lack of a decrement in intraislet insulin during hypoglycemia. This was associated with ∼30% lower plasma glucagon concentrations (109 ± 7 vs. 136 ± 9 pg/ml, P < 0.006) and increments in plasma glucagon above baseline (41 ± 8 vs. 67 ± 11 pg/ml, P < 0.008) during the last 15 min of the hypoglycemic clamp. In contrast, increases in plasma growth hormone were ∼70% greater during hypoglycemia after somatostatin infusion (P < 0.007), suggesting that to some extent the increases in plasma glucagon might have reflected a rebound in glucagon secretion.

CONCLUSIONS—These results provide direct support for the intraislet insulin hypothesis in humans. However, the exact extent to which a decrement in intraislet insulin accounts for the glucagon responses to hypoglycemia remains to be established.
Validation of a Novel Screening Device (NeuroQuick) for Quantitative Assessment of Small Nerve Fiber Dysfunction as an Early Feature of Diabetic Polyneuropathy
Authors: Ziegler Dan , Siekierka-Kleiser Ewa , Meyer Bernd , Schweers Michael
Published: March 2007

OBJECTIVE—To validate a handheld screening device (NeuroQuick) for an early detection of diabetic distal symmetric polyneuropathy (DSP) by quantitative testing of cold sensation based on the wind chill factor (NeuroQuick threshold [NQT]).

RESEARCH DESIGN AND METHODS—NQT was measured on the dorsum of the foot in 160 healthy subjects as well as 60 and 128 diabetic patients without and with DSP, respectively. DSP was diagnosed by a neurological examination, motor and sensory nerve conduction velocity, vibration perception threshold, and warm and cold thermal perception threshold (TPT) (TPT Medoc). In addition, a C-64 Hz tuning fork and TipTherm device were used as screening instruments.

RESULTS—In the diabetic cohort, NQT correlated significantly with all nerve function tests, with the highest correlation coefficients being found on the foot versus Medoc warm TPT (r = 0.618, P < 0.001) and cold TPT (r = 0.529, P < 0.001). Among patients with DSP, NQT was abnormal, whereas Medoc warm TPT was normal in 34%, whereas only 5% showed the opposite constellation (P < 0.05). Likewise, the corresponding percentages for Medoc cold TPT were 32 and 11%, for TipTherm 47 and 2%, and for the tuning fork 29 and 10% (all P < 0.05), whereas no significant differences were noted when comparing NQT with peroneal motor nerve conduction velocity, sural sensory nerve conduction velocity, and malleolar vibration perception threshold. The coefficients of variation for repeated NQT measurements in 41 control and 41 diabetic subjects were 20.4 and 8.5%, respectively.

CONCLUSIONS—The NeuroQuick is a valid and reliable screening tool for quantitative assessment of small nerve fiber dysfunction. This device appears to be more sensitive in detecting early diabetic polyneuropathy than both elaborate thermal testing and screening tests such as the tuning fork.