Combination therapy with insulin glargine plus metformin but not insulin glargine plus sulfonylurea provides similar glycemic control to triple oral combination therapy in patients with type 2 diabetes uncontrolled with dual oral agent therapy.

AIMS: Evaluate substituting insulin glargine (GLAR) for a thiazolidinedione (TZD) versus adding a third oral antidiabetes drug (OAD) in patients with uncontrolled type 2 diabetes mellitus (T2DM) on TZD+metformin or TZD+sulfonylurea. METHODS: In this multicenter, open-label study, 337 T2DM patients with a glycated hemoglobin A1c (A1C) of 7.5-12.0% despite≥3months of treatment with a TZD plus metformin or a sulfonylurea were randomized to a third OAD (3OAD; metformin or glyburide) or GLAR+1 OAD (metformin or sulfonylurea) with TZD cessation, titrated to a fasting blood glucose≤94mg/dL. RESULTS: Substitution of GLAR for a TZD led to an adjusted mean A1C change from baseline of-1.66% versus-1.86% in the 3OAD arm (adjusted mean difference 0.20 [95% confidence interval, - 0.11, 0.51], not meeting the noninferiority criteria). This difference was driven by the GLAR+sulfonylurea stratum. GLAR+metformin was as effective as 3OAD in achieving glycemic control but with greater improvements in lipid parameters, less weight gain, and lower hypoglycemia rates. CONCLUSIONS: These findings favor substitution of GLAR for a TZD in T2DM patients not controlled on TZD+metformin. GLAR+sulfonylurea was less effective at lowering A1C than 3OAD and not associated with the benefits observed with GLAR+metformin.

Defining the medical home: the Oregon experience.

OBJECTIVE: The patient-centered medical home (PCMH) is emerging as a key strategy to improve health outcomes, reduce total costs, and strengthen primary care, but a myriad of operational measures of the PCMH have emerged. In 2009, the state of Oregon convened a public, legislatively mandated committee charged with developing PCMH measures. We report on the process of, outcomes of, and lessons learned by this committee. METHODS: The Oregon PCMH advisory committee was appointed by the director of the Oregon Department of Human Services and held 7 public meetings between October 2009 and February 2010. The committee engaged a diverse group of Oregon stakeholders, including a variety of practicing primary care physicians. RESULTS: The committee developed a PCMH measurement framework, including 6 core attributes, 15 standards, and 27 individual measures. Key successes of the committee's work were to describe PCMH core attributes and functions in patient-centered language and to achieve consensus among a diverse group of stakeholders. CONCLUSIONS: Oregon's PCMH advisory committee engaged local stakeholders in a process that resulted in a shared PCMH measurement framework and addressed stakeholders' concerns. The state of Oregon now has implemented a PCMH program using the framework developed by the PCMH advisory committee. The Oregon experience demonstrates that a brief public process can be successful in producing meaningful consensus on PCMH roles and functions and advancing PCMH policy.

Practice redesign and the patient-centered medical home: history, promises, and challenges.

Medical practice redesign refers to the intentional efforts to improve practice processes and outcomes. Efforts to redesign office-based medical care go back some forty years. We divide the history of practice redesign into three overlapping phases: basic investigation, model development, and dissemination. The "medical home" movement in primary care has accelerated this dissemination phase. The acceleration and scaling up of efforts in practice redesign that have resulted from interest in the medical home present substantial opportunities and challenges for the medical profession and the U.S. health care system. We review the history and extract lessons to inform today's medical practice redesign efforts.

Early neural and vascular dysfunctions in diabetic rats are largely sequelae of increased sorbitol oxidation.

These experiments were undertaken to assess the importance of cytoplasmic (c) sorbitol oxidation versus mitochondrial (m) pyruvate oxidation in mediating neural and vascular dysfunction attributable to hyperglycemia in diabetic rats. Increased oxidation of sorbitol is coupled to enzymatic reduction of free oxidized NAD(+)c to reduced NADHc, manifested by an increased ratio of NADH to NAD(+)c. Likewise, increased oxidation of pyruvate is coupled to reduction of NAD(+)m to NADHm, which increases the NADH/NAD(+)m ratio. Specific inhibitors of sorbitol production or sorbitol oxidation normalized: increased diabetic nerve NADH/NAD(+)c, impaired nerve-conduction velocity, and vascular dysfunction in sciatic nerve, retina, and aorta; however, they had little or no impact on increased NADH/NAD(+)m. These observations provide, for the first time, strong in vivo evidence for the primacy of sorbitol oxidation versus. pyruvate oxidation in mediating the metabolic imbalances, impaired nerve conduction, and vascular dysfunction evoked by diabetes. These findings are consistent with (a) the fact that oxidation of sorbitol produces "prooxidant" NADHc uncoupled from subsequent production of "antioxidant" pyruvate required for reoxidation of NADHc to NAD(+)c by lactate dehydrogenase, and (b) the hypothesis that neural and vascular dysfunction in early diabetes are caused primarily by increased NADHc, which fuels superoxide production by NADH-driven oxidases.

Educating physicians for systems-based practice.

Training physicians in systems-based practice is a well-recognized need, yet achieving this objective has been slower than would be expected. Our continuing medical education (CME) efforts have a great influence on how physicians learn and what they learn. Merging the need to provide ongoing education with the need to help physicians become more system minded and more proficient systems managers provides great opportunities for the CME community. This paper explores the role of CME in training physicians in systems-based practice.

Efficacy and safety of the direct renin inhibitor aliskiren and ramipril alone or in combination in patients with diabetes and hypertension.

OBJECTIVE: To assess the antihypertensive efficacy and safety of the combination of the direct renin inhibitor aliskiren and ramipril in patients with diabetes and hypertension. METHODS: In this double-blind, multicentre trial, 837 patients with diabetes mellitus and hypertension (mean sitting diastolic blood pressure [BP] > 95 and < 110 mmHg) were randomised to once-daily aliskiren (150 mg titrated to 300 mg after four weeks; n=282), ramipril (5 mg titrated to 10 mg; n=278) or the combination (n=277) for eight weeks. Efficacy variables were cuff mean sitting diastolic BP (msDBP) and mean sitting systolic BP (msSBP); 24-hour ambulatory BP, plasma renin activity (PRA) and plasma renin concentration (PRC) were also assessed. RESULTS: At week 8, aliskiren, ramipril and aliskiren/ramipril lowered msDBP (mean+/-SEM) by 11.3+/-0.5, 10.7+/-0.5 and 12.8+/-0.5 mmHg, and msSBP by 14.7+/-0.9, 12.0+/-0.9 and 16.6+/-0.9 mmHg, respectively. Aliskiren/ramipril provided superior msDBP reductions to ramipril (p=0.004) or aliskiren (p=0.043) monotherapy; adding aliskiren to ramipril provided an additional mean BP reduction of 4.6/2.1 mmHg. Aliskiren monotherapy was non-inferior to ramipril for msDBP reduction (p=0.0002) and superior for msSBP reduction (p=0.021). All treatments significantly lowered mean 24-hour ambulatory BP. Aliskiren significantly reduced PRA from baseline as monotherapy (by 66%, p<0.0001) or in combination with ramipril (by 48%, p<0.0001), despite large increases in PRC in all treatment groups. Aliskiren was well tolerated as monotherapy or in combination with ramipril. CONCLUSIONS: Combining aliskiren with ramipril provided a greater reduction in msDBP than either drug alone in patients with diabetes and hypertension.

Evaluation of a new blood glucose monitoring system with auto-calibration for home and hospital bedside use.

A new self-calibrating blood glucose monitoring system (BGMS) was evaluated in a series of clinical studies with both ambulatory subjects and with hospitalized patients. The new BGMS requires a 0.6microL sample volume, provides results in 15s, and uses a glucose dehydrogenase chemistry that is oxygen independent. In the first study, Ascensia Contour meters calibrated to whole blood were tested by health care professionals (HCP) and lay users at two clinical sites. Both HCPs and lay users obtained results that fulfilled the ISO 15197:2003 criteria that 95% of self-monitoring blood glucose (SMBG) measurements should fall within +/-20% (for blood glucose (BG) concentrations> or =4.2mmol/L or +/-0.83mmol/L for BG concentrations<4.2mmol/L) of the laboratory value. Lay users and HCPs obtained 97.2 and 96.7% of glucose results within ISO criteria, respectively. In a second study, HCPs assayed blood samples from patients at the hospital bedside using meters calibrated to give whole blood glucose and meters calibrated to give plasma glucose results. Overall, 94.7% of the measurements met the ISO 15197:2003 criteria. Most lay subjects rated the BGMS as either excellent or very good in a questionnaire, and were able to use it properly without training. These findings indicate that this new BGMS is a convenient and accurate instrument system suitable for both hospital bedside use by HCPs and for SMBG by people who routinely monitor their blood glucose.

Transforming care: medical practice design and information technology.

The transformation of the medical practice is possible today because of the advancement of system design knowledge coupled with innovations in information technology (IT). Examples of such transformed care are present today, and they are creating a roadmap for others. Those efforts are also elucidating critical issues in the use of IT to advance health care quality. Connectivity, electronic integration, and knowledge management are the key functionalities emerging as levers to promote this transformation.

Evaluation of a new blood glucose monitoring system with auto-calibration.

BACKGROUND: The Ascensia CONTOUR System (Bayer HealthCare LLC, Elkhart, IN) is a new blood glucose (BG) monitoring system (BGMS) that uses glucose dehydrogenase chemistry and that combines low sample volume, fast response time, an auto-control marking feature, and an auto-calibration function in a small package. METHODS: The system was evaluated at four diabetes clinics with ambulatory subjects who had diabetes. The BGMS was tested by both health care professionals (HCPs) and lay users. It was also evaluated at high altitude (10,200 feet) and, in conjunction with the Ascensia MICROLET VACULANCE (Bayer), for use with samples obtained from four alternative anatomical sites. RESULTS: When the system was used with blood from fingersticks, both lay users and HCPs obtained results that fulfilled the International Organization for Standardization (ISO) 15197:2003 accuracy criteria, which advocate that 95% of BG measurements should fall within +/-15 mg/dL (for BG concentrations <75 mg/dL) or +/-20% (for BG concentrations > or = 75 mg/dL) of the laboratory value. Lay users obtained 96.9% of glucose results, and HCPs obtained 96.4% of glucose results, within ISO accuracy criteria. People with diabetes who had no prior experience using the system also obtained acceptable results (97.0%), as did the HCP using fingerstick samples from subjects in the high altitude study (97.0%). Among the alternative anatomical sites tested, only the results from the palm met the ISO criteria (97.5%), although the results from all four sites (palm, thigh, abdomen, and forearm) were clinically acceptable when assessed using error grid analysis. Most subjects rated the BGMS as either excellent or very good in a questionnaire, and were able to use it properly without training. CONCLUSIONS: These findings indicate that the Ascensia CONTOUR System, which does not require calibration by the user, is a convenient and accurate instrument with useful features for people who routinely monitor BG.

Interactions between hyperglycemia and hypoxia: implications for diabetic retinopathy.

The primary aim of these experiments was to assess in vitro effects of hyperglycemia (30 mmol/l glucose) and hypoxia (Po(2) = 36 torr) of 2-h duration, separately and in combination, on cytosolic and mitochondrial free NADH (NADHc and NADHm, respectively) in retinas from normal rats. NADH is the major carrier of electrons and protons that fuel ATP synthesis and several metabolic pathways linked to diabetic complications. Hyperglycemia and hypoxia increase free NADHc by different mechanisms that are additive. Hyperglycemia increases transfer of electrons and protons from sorbitol to NAD(+)c, reducing it to NADHc, but does not increase NADHm. Hypoxia increases NADHm by inhibiting its oxidation. Electrons and protons accumulating in NADHm restrain transfer of electrons and protons from NADHc to NAD(+)m via the malate-aspartate electron shuttle. Hyperglycemia and hypoxia also increase glycolysis by different mechanisms that are additive, and hyperglycemia increases ATP levels in hypoxic and in aerobic retinas. The additive effects of hyperglycemia and hypoxia on accumulation of electrons and protons in a common pool of free NADHc confirm the test hypothesis and the potential of a combination of these two risk factors to accelerate the onset and progression of diabetic retinopathy (and other complications of diabetes) by augmenting metabolic pathways fueled by free NADHc.

Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease.

BACKGROUND: Liposuction has been proposed as a potential treatment for the metabolic complications of obesity. We evaluated the effect of large-volume abdominal liposuction on metabolic risk factors for coronary heart disease in women with abdominal obesity. METHODS: We evaluated the insulin sensitivity of liver, skeletal muscle, and adipose tissue (with a euglycemic-hyperinsulinemic clamp procedure and isotope-tracer infusions) as well as levels of inflammatory mediators and other risk factors for coronary heart disease in 15 obese women before and 10 to 12 weeks after abdominal liposuction. Eight of the women had normal glucose tolerance (mean [+/-SD] body-mass index, 35.1+/-2.4), and seven had type 2 diabetes (body-mass index, 39.9+/-5.6). RESULTS: Liposuction decreased the volume of subcutaneous abdominal adipose tissue by 44 percent in the subjects with normal glucose tolerance and 28 percent in those with diabetes; those with normal oral glucose tolerance lost 9.1+/-3.7 kg of fat (18+/-3 percent decrease in total fat, P=0.002), and those with type 2 diabetes lost 10.5+/-3.3 kg of fat (19+/-2 percent decrease in total fat, P<0.001). Liposuction did not significantly alter the insulin sensitivity of muscle, liver, or adipose tissue (assessed by the stimulation of glucose disposal, the suppression of glucose production, and the suppression of lipolysis, respectively); did not significantly alter plasma concentrations of C-reactive protein, interleukin-6, tumor necrosis factor alpha, and adiponectin; and did not significantly affect other risk factors for coronary heart disease (blood pressure and plasma glucose, insulin, and lipid concentrations) in either group. CONCLUSIONS: Abdominal liposuction does not significantly improve obesity-associated metabolic abnormalities. Decreasing adipose tissue mass alone will not achieve the metabolic benefits of weight loss.

Starting patients with type 2 diabetes on insulin therapy using once-daily injections of biphasic insulin aspart 70/30, biphasic human insulin 70/30, or NPH insulin in combination with metformin.

Transitioning safely to insulin therapy when oral antidiabetic agents fail to provide adequate glycemic control is a critical aspect of care for the patient with type 2 diabetes mellitus (T2DM). We evaluated the clinical effectiveness of starting patients on a relatively simple regimen of once-daily injections of either biphasic insulin aspart 70/30 (10 min before dinner), NPH insulin (at 10 p.m.), or biphasic human insulin 70/30 (30 min before dinner) in combination with metformin. Enrolled patients had T2DM and inadequate glycemic control (AlC>/=7.5%) on a previous regimen of metformin as monotherapy or in combination with a sulphonylurea. One hundred and forty (140) patients received metformin monotherapy for 4 weeks followed by 12 weeks of combination treatment with metformin and once-daily insulin injections. AlC levels decreased from baseline by 1.1-1.3% for patients in each of the three treatment groups. Overall, FPG values decreased from baseline by 31% (biphasic insulin aspart), 37% (NPH insulin), and 28% (biphasic human insulin). Subjects whose final FPG level was <126 mg/dl experienced the largest decreases in AlC values (-2.3%, -1.9%, -1.8%, respectively). All three treatment regimens were well tolerated. The results indicate that patients with T2DM can safely and effectively begin insulin therapy using once-daily injections of biphasic insulin aspart 70/30, biphasic human insulin 70/30, or NPH insulin in combination with metformin.