We begin with headlines. In this section, we share a few lines about newsworthy articles that you need to know about. After the headlines, we'll share abstracts on wound repair in type 1 diabetes, African American youth with type 2 diabetes, the ethics of screening for diabetes in newborns, diabetes patients and communication with physicians, C-peptide protein as a predictor of diabetes in middle-aged men, and finally the undertreatment of women with heart disease. Let's get into those headlines first. We frequently report on cardiovascular disease as it relates to diabetes because heart disease risk is so high in our population. The Strong Heart Study, which examined risk factors in 13 America Indian communities, examined whether non-HDL cholesterol, which is a measure of total cholesterol minus HDL, is a predictor of coronary vascular disease (CVD). The result of the study is that it was indeed particularly useful in predicting CVD risk in patients with diabetes. Now when you go in for your next doctor's appointment, you can ask about having proper blood work so that preventative measure can be taken.
Diabetes Care 26:443-436.2003 has an excellent article by Harold S. Starkman, MD et al who looked at the incidence of Coronary Artery Calcification (CAC) in young people aged 20-30 with no history of diabetes, and in those with type 1 diabetes. The reason being that having type 1 diabetes brings an increased risk for developing coronary heart disease. This population has a 30-40% mortality rate as compared to 4-5% in the ondiabetic population. The incidence of CAC in the first group without diabetes was 8.8% in men and 1.2% in women. In the second group, the people with diabetes, the percentages were 15.1% for men and 6.3% for women. It was concluded that using electron beam tomography can measure CAC and that is an early marker for coronary heart disease. This is something you may want to discuss with your health care team to keep an eye on a potential process. It also gives us even more reasons for tight control of type 1 diabetes at an early age.
Circulation had an article discussing that in women with metabolic syndrome, blood levels of C-peptide protein (CPP) can help predict cardiovascular risk. We all know that metabolic syndrome puts people at high risk for developing type 2 diabetes and here we have evidence that shows how important it is to control the symptoms even if you do not have diabetes.
The Archives of Internal Medicine looks at avoiding diabetic emergencies, which lead to hospitalizations in levels of SES. The results may not surprise you, but they make us pause and think about how to control medical costs in a health care system that many feel needs some work. In this Canadian study the researchers found, even when some economic barriers to accessing care are removed, patients from low-SES neighborhoods still experience an excess number of hospitalizations for conditions that should be prevented by optimal care in the ambulatory setting.
Now, it's time to look at those abstracts. Our first one is from the Archives of Surgery,2003;138:34-40 and is titled Decrease of collagen in wound repair in type 1 diabetes independent of glycemic control, by Eva Black, M.D. et al. It has long been thought that in both type 1 and type 2 diabetes, glycemic control influences wound healing. The researchers examined 34 patients with type 1 diabetes, 25 with type 2 diabetes and 5 nondiabetic controls matched with the type 2 diabetics for wound-healing capacity determined as subcutaneous accumulation of collagen measured by hydroxyproline. The hydroxyproline level was determined by means of high-performance liquid chromatography; the collagenase activity was examined by using a radiolabeled collagen substrate. Proliferation of fibroblasts cultured from the wounds was studied in patient groups. The results indicated that collagen deposition in acute wounds is impaired in type 1 diabetes, possibly due to decreased fibroblast proliferation. In type 2 diabetes, collagen is normal. Glycemic control does not influence collagen deposition in acute wound repair in type 1 or in type 2 diabetes.
The Archives of Internal Medicine, 2003:163:69-75 has an article titled Association of younger age with poor glycemic control and obesity in urban Americans with type 2 diabetes by Imad M. El-Kebbi, M.D. et al. The researcher examined all patients with type 2 diabetes seen in a Diabetes clinic in Atlanta, GA. Each participant had an HbA1c level measured at their initial visit and at follow-up 5 to 12 months later. Patients were divided into 4 age categories: less than 30 years, 30-49 years, 50-69 years, and more than 69 years. At baseline, average HbA1c levels were 9.9%, 9.5%, 9.2%, and 8.8% in the four groups, respectively. Body mass indexes were 37.8, 33.9, 31.6, and 29.2 respectively. 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 HbA1c level at follow-up. They also found that HbA1c level and body mass index were negatively correlated with age. The team concluded that there is a high prevalence of obesity and poor glycemic control in young adult urban African Americans with diabetes.
The Ethics of predictive diabetes mellitus screening research in newborns by Lainie Friedman Ross, MD, PhD is found the Archives of Pediatrics and Adolescent Medicine 2003; 157:89-95. The author states that diabetes mellitus is the most common metabolic disease of childhood. Currently two states offer newborn screening to identify children with a genetic disposition to diabetes; it is voluntarily offered in conjunction with mandatory newborn metabolic screening. There are no preventative treatments, but children discovered to be at increased risk may participate in follow-up studies to determine whether and when the child develops autoantibodies (pre-clinical disease) or overt diabetes. This study examined the ethics of predictive genetic research in newborns for type 1 diabetes. Prediction research has serious psychosocial implications, and research designs must account for them. The study concluded that, to minimize harm to infants and their families, (1) if the research does not incorporate a prevention strategy, studies should avoid disclosure of results; and (2) if disclosure is necessary, then the research should be restricted to newborns with a affected first-degree relative.
The Archives of Internal Medicine 2003;163:83-90 has an article titled Physician communication with diabetic patients who have low health literacy by Dean Schillinger, MD et al. Data indicates that patients recall or comprehend as little as half of what physicians convey during an outpatient encounter. To enhance recall, comprehension, and adherence, it is recommended that physicians elicit patients' comprehension of new concepts and tailor subsequent information, particularly for patients with low functional health literacy. It is not known how frequently a physician applies this interactive educational strategy, or whether it is associated with improved health outcomes. The researchers used direct observation to measure the extent to which primary care physicians working in a public hospital assess patient recall and comprehension of new concepts, using audiotapes of visits between 38 physicians and 74 English-speaking patients with diabetes and low functional literacy. They then looked at whether there was an association between physicians' application of this interactive communication strategy and patients' glycemic control, using information from clinical and administrative databases. The results were telling, because it was found that primary care physicians caring for this population rarely assessed patient recall or comprehension of new concepts. Overlooking this step in communication reflects a missed opportunity that may have important clinical implications.
The Archives of Internal Medicine 2003;163:93-99 has an article titled C-peptide protein as a predictor for incident diabetes mellitus among middle-aged men, results from the MONICA Augsburg cohort study, 1984-2998 by Barbara Thorand, PhD. MPH et al. Previous studies have suggested that low-grade systemic inflammation is involved in the pathogenesis of type 2 diabetes mellitus. To investigate the association between C-reactive protein (CRP), the classic acute-phase protein, and incident type 2 diabetes in middle aged men, a total of 2052 initially nondiabetic men aged 45 to 74 years who participated in 1 of the 3 MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) Augsburg surveys. These men were followed up for an average of 7.2 years. Incidence of diabetes was assessed by questionnaire mailed to participants in 1998. High-sensitive CRP was measured by an immuno-radiometric assay. A total of 101 cases of incident diabetes occurred during the follow-up period. The age-standardized incidence rate was 6.9 per 1000 person years. Men with CRP levels in the highest quartile had a 2.7 times higher risk of developing diabetes compared with men in the lowest quartile in a Cox proportional hazard model adjusted for age and survey. After further adjustment for body mass index, smoking, and systolic blood pressure, the observed association was significantly reduced and became non-significant. They concluded that low-grade systemic inflammation is associated with an increased risk of type 2 diabetes in middle-aged men. Inflammation could be one mechanism by which known risk factors for diabetes mellitus, such as obesity, smoking, and hypertension, promote and develop diabetes mellitus.
Women seen undertreated for heart disease is an article in the Annals of Internal Medicine, Jan, 2003 by Michael Shlipak et al. They found that many women who suffer heart attacks are not getting adequate treatment. The study found that doctors often fail to prescribe aspirin, beta blockers and cholesterol-lowering drugs to these women, even though the medications have been shown to prevent further heart attacks or other heart trouble. It was felt that there is a lingering myth that heart disease is primarily a man's disease. Moreover, doctors and patients fear the side effects of some preventative medications. The study involved 2,763 postmenopausal women with heart disease. All had suffered heart attacks or chest pains caused by clogged arteries, or had undergone bypass surgery or angioplasty. Researchers found that beta blockers, which slow the heart rate, were used by only a third of the women who should have been taking them. Only half the women who qualified for cholesterol-lowering drugs took them. Even aspirin was underused. Though all of the heart attack survivors in the study should have been taking it, only 80% did. The research highlights a terrible discrepancy between what doctors know and how women are treated. This research comes as a word to the wise to all women with diabetes as we have a high risk factor for cardiovascular disease. Make sure you are educated about the treatment of heart disease and make sure your physician talks with you, your mother or sister about the approved ways of treating CVD. If you have symptoms of CVD make sure you are evaluated and not sent home with a diagnosis of heartburn, and most of all make sure you have a good relationship with your health care team so that you know your care will class "A".
BSP
