Diabetes Risk Assessment in Latinas: Effectiveness of a Brief Diabetes Risk Questionnaire for Detecting Prediabetes in a Community-Based Sample.

OBJECTIVE: Numerous validated questionnaires use self-reported data to quantify individuals' risk of having diabetes or developing it in the future. Evaluations of these tools have primarily used nationally representative data, limiting their application in clinical and community settings. This analysis tested the effectiveness of the American Diabetes Association (ADA) risk questionnaire for identifying prediabetes in a community-based sample of Latinas. METHODS: Data were collected using the ADA risk questionnaire and assessing A1C. Among 204 participants without diabetes, we examined the association between individual characteristics and glycemic status. We then calculated the performance characteristics (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of the ADA risk questionnaire for detecting prediabetes, using A1C results as the gold standard to define the outcome. RESULTS: All participants were women of self-reported Hispanic/Latino ethnicity. Their mean ADA risk score was 5.6 ± 1.6. Latinas who had prediabetes were older, with significantly higher rates of hypertension and a higher ADA risk score than those without prediabetes. At a risk score ≥5-the threshold for high risk set by the ADA-the questionnaire had the following test performance characteristics: sensitivity 77.8%, specificity 41.7%, PPV 76.2%, and NPV 43.9%. CONCLUSION: The ADA risk questionnaire demonstrates reasonable performance for identifying prediabetes in a community-based sample of Latinas. Our data may guide other groups' use of this tool in the same target population. Future research should examine the effectiveness of this questionnaire for recruiting diverse populations into diabetes prevention programs. In addition, unique diabetes risk assessment tools for specific target populations are needed and may outperform questionnaires developed using nationally representative data.

Macronutrient Composition or Social Determinants? Impact on Infant Outcomes With Gestational Diabetes Mellitus.

The purpose of this study was to examine, through a randomized, controlled trial, the effects of a maternal carbohydrate-restricted diet on maternal and infant outcomes in gestational diabetes mellitus (GDM). Women diagnosed with GDM were randomly allocated into one of two groups: an intervention group that was placed on a lower-carbohydrate diet (35-40% of total calories) or a control group that was placed on the usual pregnancy diet (50-55% carbohydrate). A convenience sample of participants diagnosed with GDM (ages 18-45 years) was recruited from two different sites: one urban and low-income and the other suburban and more affluent. Individual face-to-face diet instruction occurred with certified diabetes educators at both sites. Participants tested their blood glucose four times daily. Specific socioeconomic status indicators included enrollment in the Supplemental Nutrition Program for Women, Infants and Children or Medicaid-funded health insurance, as well as cross-sectional census data. All analyses were based on an intention to treat. Although there were no differences found between the lower-carbohydrate and usual-care diets in terms of blood glucose or maternal-infant outcomes, there were significant differences noted between the two sites. There was a lower mean postprandial blood glucose (100.59 ± 7.3 mg/dL) at the suburban site compared to the urban site (116.3 ± 15 mg/dL) (P <0.01), even though there was no difference in carbohydrate intake. There were increased amounts of protein and fat consumed at the suburban site (P <0.01), as well as lower infant complications (P <0.01). Further research is needed to determine whether these disparities in outcomes were the result of macronutrient proportions or environmental conditions.

Diabetes-related autoantibodies in diabetic gastroparesis.

BACKGROUND: Detection of islet autoantibodies [anti-glutamic acid decarboxylase antibody (GADA), anti-islet cell antibody (ICA), anti-insulin antibody (IAA)] in patients with diabetes usually indicates an autoimmune origin, suggesting type 1 diabetes (T1DM). The aim of our study was to determine whether islet autoantibodies are present in patients with diabetic gastroparesis and whether they associate with delayed gastric emptying, severity of GI symptoms, or diagnosed type of diabetes. METHODS: Patients with diabetic gastroparesis completed: (1) Demographic Questionnaire assessing type of diabetes, associated symptoms and control of glucose and (2) Patient Assessment of GI Symptoms assessing symptoms severity. Blood was drawn for GADA, anti-islet cell ICA-IAA, and Hgb-A1c. Medical records were reviewed for gastric emptying tests and to confirm type of diabetes. RESULTS: Sixteen patients (12 T1DM; 4 diagnosed T2DM) with diabetic gastroparesis were evaluated. Six of the 16 patients tested positive for GADA, but none were positive for either ICA or IAA. Five of 12 T1DM patients had positive GADA, compared to one of four diagnosed as T2DM. The presence of antibodies was associated with the age of onset of gastroparesis symptoms, but not related to gastric emptying delay, symptom severity, HBA1c levels, or age. CONCLUSIONS: This pilot study demonstrated that of the three tested antibodies in long-term diabetic gastroparesis patients, GADA was the most prevalent positive antibody with no detection of ICA or IAA. Positive GADA was seen in 42 % of T1DM compared to 25 % of phenotypic T2DM. However, the presence of antibody was not associated with severity of gastric emptying or GI symptoms. Thus, detection of an autoimmune form of diabetes, primarily T1DM, should be investigated using GADA.

Foods provoking and alleviating symptoms in gastroparesis: patient experiences.

BACKGROUND: Nutritional counseling for gastroparesis focuses on reduction of meal size, fiber, and fat to control symptoms. The tolerance of gastroparesis patients for particular foods is largely anecdotal. The aim of this study was to identify and characterize foods provoking or alleviating gastroparesis symptoms. METHODS: Gastroparesis patients completed: (1) Demographic Questionnaire; (2) Patient Assessment of Upper GI Symptoms; (3) Food Toleration and Aversion survey asking patients about experiences when eating certain foods utilizing a scale from -3 (greatly worsening symptoms) to +3 (greatly improving symptoms). Descriptive qualities (acidic, fatty, spicy, roughage-based, bitter, salty, bland, and sweet) were assigned to foods. RESULTS: Forty-five gastroparesis patients participated (39 idiopathic gastroparesis). Foods worsening symptoms included: orange juice, fried chicken, cabbage, oranges, sausage, pizza, peppers, onions, tomato juice, lettuce, coffee, salsa, broccoli, bacon, and roast beef. Saltine crackers, jello, and graham crackers moderately improved symptoms. Twelve additional foods were tolerated by patients (not provoking symptoms): ginger ale, gluten-free foods, tea, sweet potatoes, pretzels, white fish, clear soup, salmon, potatoes, white rice, popsicles, and applesauce. Foods provoking symptoms were generally fatty, acidic, spicy, and roughage-based. The foods shown to be tolerable were generally bland, sweet, salty, and starchy. CONCLUSIONS: This study identified specific foods that worsen as well as foods that may help alleviate symptoms of gastroparesis. Foods that provoked symptoms differed in quality from foods that alleviated symptoms or were tolerable. The results of this study illustrate specific examples of foods that aggravate or improve symptoms and provide suggestions for a gastroparesis diet.

Managing hypertension in urban underserved subjects using telemedicine--a clinical trial.

BACKGROUND: We evaluated an Internet- and telephone-based telemedicine system for reducing blood pressure (BP) in underserved subjects with hypertension. METHODS: A total of 241 patients with systolic BP ≥140 mm Hg were randomized to usual care (C; n = 121) or telemedicine (T; n = 120). The T group reported BP, heart rate, weight, steps/day, and tobacco use twice weekly. The primary outcome was BP control at 6 months. RESULTS: Average age was 59.6 years, average body mass index was 33.7 kg/m(2), 79% were female, 81% were African American, 15% were white, 53% were at or below the federal poverty level, 18% were smokers, and 32% had diabetes. Six-month follow-up was achieved in 206 subjects (C: 107, T: 99). Goal BP was achieved in 52.3% in C and 54.5% in T (P = .43). Systolic BP change (C: -13.9 mm Hg, T: -18.2; P = .118) was similar in both groups. Subjects in the T group reported BP 7.7 ± 6.9 d/mo. Results were not affected by age, sex, ethnicity, education, or income. In nondiabetic T subjects, goal BP was achieved in 58.2% compared with 45.2% of diabetic T subjects (P = .024). Nondiabetic T subjects demonstrated a greater reduction in systolic BP (T: -19 ± 20 mm Hg, C: -12 ± 19 mm Hg; P = .037). No difference in BP response between C and T was noted in patients with diabetes. CONCLUSION: In hypertensive subjects, engagement in a system of care with or without telemedicine resulted in significant BP reduction. Telemedicine for nondiabetic patients resulted in a greater reduction in systolic BP compared with usual care. Telemedicine may be a useful tool for managing hypertension particularly among nondiabetic subjects.

The role of telemedicine in the management of the pregnancy complicated by diabetes.

The use of technology to deliver health care over a distance has drawn considerable attention and shown dramatic growth over the last decade because of the possibility it has to reduce cost and improve access to modern medical care. Diabetes in pregnancy, which requires tight glycemic control in order to reduce perinatal complications, is a prime telemedicine intervention target. A review of the literature suggests that telemedicine, although not perfect, can potentially play a role in reducing patient visits and could improve quality of life without jeopardizing the outcome.

Clinical significance of troponin elevations in acute decompensated diabetes without clinical acute coronary syndrome.

BACKGROUND: Elevation of cardiac troponin has been documented in multiple settings without acute coronary syndrome. However, its impact on long-term cardiac outcomes in the context of acute decompensated diabetes remains to be explored. METHODS: We performed a retrospective analysis of 872 patients admitted to Temple University Hospital from 2004-2009 with DKA or HHS. Patients were included if they had cardiac troponin I (cTnI) measured within 24 hours of hospital admission, had no evidence of acute coronary syndrome and had a follow up period of at least 18 months. Of the 264 patients who met the criteria, we reviewed the baseline patient characteristics, admission labs, EKGs and major adverse cardiovascular events during the follow up period. Patients were categorized into two groups with normal and elevated levels of cardiac enzymes. The composite end point of the study was the occurrence of a major cardiovascular event (MACE) during the follow up period and was compared between the two groups. RESULTS: Of 264 patients, 24 patients were found to have elevated cTnI. Compared to patients with normal cardiac enzymes, there was a significant increase in incidence of MACE in patients with elevated cTnI. In a regression analysis, which included prior history of CAD, HTN and ESRD, the only variable that independently predicted MACE was an elevation in cTnI (p = 0.044). Patients with elevated CK-MB had increased lengths of hospitalization compared to the other group (p < 0.001). CONCLUSIONS: Elevated cardiac troponin I in patients admitted with decompensated diabetes and without evidence of acute coronary syndrome, strongly correlate with a later major cardiovascular event. Thus, elevated troponin I during metabolic abnormalities identify a group of patients at an increased risk for poor long-term outcomes. Whether these patients may benefit from early detection, risk stratification and preventive interventions remains to be investigated.

Reducing cardiovascular disease risk in medically underserved urban and rural communities.

OBJECTIVES: The aim of this study is to evaluate methods for lowering cardiovascular disease (CVD) risk in asymptomatic urban and rural underserved subjects. BACKGROUND: Medically underserved populations are at increased CVD risk, and systems to lower CVD risk are needed. Nurse management (NM) and telemedicine (T) systems may provide low-cost solutions for this care. METHODS: We randomized 465 subjects without overt CVD, with Framingham CVD risk >10% to NM with 4 visits over 1 year, or NM plus T to facilitate weight, blood pressure (BP), and physical activity reporting. The study goal was to reduce CVD risk by 5%. RESULTS: Three hundred eighty-eight subjects completed the study. Cardiovascular disease risk fell by ≥ 5% in 32% of the NM group and 26% of the T group (P, nonsignificant). In hyperlipidemic subjects, total cholesterol decreased (NM -21.9 ± 39.4, T -22.7 ± 41.3 mg/dL) significantly. In subjects with grade II hypertension (systolic BP ≥ 160 mm Hg, 24% of subjects), both NM and T groups had a similar BP response (average study BP: NM 147.4 ± 17.5, T 145.3. ± 18.4, P is nonsignificant), and for those with grade I hypertension (37% of subjects), T had a lower average study BP compared to NM (NM 140.4 ± 16.9, T 134.6 ± 15.0, P = .058). In subjects at high risk (Framingham score ≥ 20%), risk fell 6.0% ± 9.9%; in subjects at intermediate risk (Framingham score ≥ 10, < 20), risk fell 1.3% ± 4.5% (P < .001 compared to high-risk subjects). Medication adherence was similar in both high- and intermediate-risk subjects. CONCLUSIONS: In 2 underserved populations, CVD risk was reduced by a nurse intervention; T did not add to the risk improvement. Reductions in BP and blood lipids occurred in both high- and intermediate-risk subjects with greatest reductions noted in the high-risk subjects. Frequent communication using a nurse intervention contributes to improved CVD risk in asymptomatic, underserved subjects with increased CVD risk. Telemedicine did not change the effectiveness of the nurse intervention.

Treatment of patients with intermediate cardiovascular risk: Are clinical measures enough?

AIM: Clinical measures of cardiovascular disease risk (CVD) are important tools for establishing therapy to lower CVD risk. Risk assessment has come under criticism because clinical measures can underestimate or overestimate CVD risk. We assessed CVD risk in 252 subjects without evidence of CVD to establish therapy of one or more risk factors from clinical indications. The subjects all had intermediate CVD risk using the Framingham score. RESULTS: Average age was 59.1 years. 23.8% were smokers, 59.1% were hypertensive, 65.1% had hyperlipidemia. BMI was greater than 30 kg/M(2) in 56% and diabetes was present in 43.7%. In this cohort, 86.9% required therapy for hypertension or hyperlipidemia, and this proportion increased to 95.6% when subjects with diabetes were included. Of the remaining 4.4% (11 subjects), 7 reached intermediate risk based on cigarette smoking and 4 based on age >65 years old. Among diabetics, 94/110 had another risk factor and would require statin and ACE or ARB therapy. CONCLUSIONS: Of subjects at intermediate risk for CVD, 98.4% would not require further testing to decide on therapy to lower CVD risk. Although 16 diabetic subjects had no other risk factors, current guidelines suggest that these subjects should be treated to reduce CVD risk.

Gestational diabetes screening after HAPO: has anything changed?

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy. It is defined as diabetes that is first recognized during pregnancy. The diagnosis of GDM is important because it impacts maternal health care during and after pregnancy. The American Diabetes Association, American Congress of Obstetrics and Gynecology, the World Health Organization, and the National Diabetes Data Group all have recommendations for screening; however, there is no consensus. The Hyperglycemia and Adverse Pregnancy Outcome Research Cooperative Study Group published their findings that show hyperglycemia has a significant effect on pregnancy outcome. In addition, recent studies showed that treatment of mild hyperglycemia may affect adverse outcomes. However, at this time no new guidelines for screening and diagnosis of gestational diabetes have been published. This article summarizes the current state of screening for gestational diabetes.

Insulin resistance: the possible link between gestational diabetes mellitus and hypertensive disorders of pregnancy.

Gestational hypertension, preeclampsia, and diabetes are all associated with increased risks of poor maternal and perinatal outcomes. Pregnant women with gestational diabetes have been shown in population studies to have increased risk of pregnancy-associated hypertension compared with nondiabetic women. Moreover, pregnant patients with hypertension are at increased risk for developing gestational diabetes mellitus. It has been hypothesized that this association could be due, at least in part, to insulin resistance. Although insulin resistance is a physiologic phenomenon in normal pregnancy, in predisposed individuals this could lead to hyperinsulinemia with the development of gestational hypertension, gestational diabetes mellitus, or both.

Person-Centered Primary Care and Type 2 Diabetes: Beyond Blood Glucose Control.

With an estimated 9% of persons in the United States diagnosed with diabetes, primary care providers such as midwives and nurse practitioners are increasingly working with persons who have diabetes and are seeking primary care services. This article reviews the current literature with regard to the initial evaluation of individuals who are diagnosed with diabetes, and what is entailed in comprehensive continuing management of care. A person-centered interprofessional approach to care of the person with diabetes is presented. Recommendations are given that address dietary habits, activities of daily living, medication regimens, and potential alternative therapies. Social constructs related to effective care of individuals with diabetes also are addressed. Knowledge of current research that has identified effective care practices for individuals with diabetes is imperative to ensuring their well-being, and promoting a person-centered and interprofessional approach is best for offering optimal care to those diagnosed with diabetes.

Combined use of rosiglitazone and fenofibrate in patients with type 2 diabetes: prevention of fluid retention.

Elevated plasma free fatty acid (FFA) levels are responsible for much of the insulin resistance in obese patients with type 2 diabetes. To lower plasma FFA levels effectively and long term, we have treated eight obese patients with type 2 diabetes for 2 months with placebo followed by 2 months of treatment with a combination of rosiglitazone (RGZ) (8 mg/day) and fenofibrate (FFB) (160 mg/day) in a single-blind placebo-controlled study design. Compared with placebo, RGZ/FFB lowered mean 24-h plasma FFA levels 30% (P < 0.03) and mean 24-h glucose levels 23% (P < 0.03) and increased insulin-stimulated glucose uptake (glucose rate of disappearance [G(R)(d)], determined using euglycemic-hyperinsulinemic clamp) 442% (P < 0.01), oral glucose tolerance (area under the curve for 3-h oral glucose tolerance test) 28% (P < 0.05), and plasma adiponectin levels 218% (P < 0.01). These RGZ/FFB results were compared with results obtained in five patients treated with RGZ alone. RGZ/FFB prevented the fluid retention usually associated with RGZ (-1.6 vs. 5.6%, P < 0.05), lowered fasting plasma FFA more effectively than RGZ alone (-22 vs. 5%, P < 0.05), and tended to be more effective than RGZ alone in lowering A1C (-0.9 vs. -0.4%) and triglyceride levels (-38 vs. -5%) and increasing G(Rd) (442 vs. 330%). We conclude that RGZ/FFB is a promising new therapy for type 2 diabetes that lowers plasma FFA more than RGZ alone and in contrast to RGZ does not cause water retention and weight gain.

Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease.

BACKGROUND: Cardiovascular disease (CVD) risk factor awareness and knowledge are believed to be prerequisites for adopting healthy lifestyle behaviors. The purpose of this study was to examine knowledge of CVD risk factors and risk perception among individuals with high CVD risk. METHODS: The sample consisted of inner city and rural medically underserved patients at high risk of CVD. To be eligible for the trial, subjects were required to have a 10% or greater CVD risk on the Framingham risk score. Knowledge of CVD was assessed with a 29-item questionnaire created for this study. Subjects also rated their perception of risk as compared with individuals of their own sex and age. RESULTS: Data were collected from 465 subjects (mean [SD] age, 60.5 [10.1] years; mean [SD] Framingham risk score, 17.3% [9.5%]). The mean (SD) CVD knowledge score was 63.7% (14.6%), and mean (SD) level of risk perception was 0.35 (1.4). Men and women had similar Framingham risk scores, but women perceived their risk to be significantly higher than that of their male counterparts. Women were also more knowledgeable than men about CVD. Urban participants had significantly higher actual risks than did their rural counterparts (18.2% [10.7%] vs 16.0% [8.9%], respectively; P = .01) but were significantly less knowledgeable about heart disease and also perceived their risk to be lower. CONCLUSIONS: These results indicate a low perception of risk and cardiovascular knowledge especially among men and inner city residents. Innovative educational strategies are needed to increase risk factor knowledge and awareness among at-risk individuals.

Accuracy of blood pressure measurements transmitted through a telemedicine system in underserved populations.

In underserved populations, inadequate surveillance and treatment allows hypertension to persist until actual cardiovascular events occur. Thus, we developed an Internet-based telemedicine system to address the suboptimal control of hypertension and other modifiable risk factors. To minimize cost, the subjects used home monitors for blood pressure (BP) measurements and entered these values into the telemedicine system. We hypothesized that patients could accurately measure their BP and transmit these values via a telemedicine system. Inner city and rural subjects (N = 464; 42% African-American or Hispanic) with 10% or greater 10-year risk of cardiovascular disease and with treatable risk factors were randomized into two groups, control group (CG) and telemedicine group (TG). Each subject received a home sphygmomanometer with memory. The TG recorded and entered BP at least weekly. During office visits, the BP meters were downloaded and recorded BP compared to BP values transmitted via telemedicine. The telemedicine (T) BP values were similar to the meter recorded (R) values (T: systolic/diastolic BP 133.4 +/- 11.1/77.5 +/- 6.8 mm Hg, and R: systolic/diastolic BP 136.4 +/- 11.9.4/79.7 +/- 7.5 mm Hg). The percent error was <1% for both systolic (-0.02 +/- 0.04%) and diastolic (-0.03 +/- 0.04%) BP. Lastly, the telemedicine BP values were similar to the office (O) BP values for systolic and diastolic BP (T: systolic/diastolic BP 133.4 +/- 11.1/77.5 +/- 6.8 mm Hg, and O: systolic/diastolic BP 136.3 +/- 20.5/78.1 +/- 10.5 mm Hg). In underserved populations, this inexpensive approach of patients using a home monitor and entering these values into a telemedicine system provided accurate BP data.

Islet Cell Associated Autoantibodies and C-Peptide Levels in Patients with Diabetes and Symptoms of Gastroparesis.

INTRODUCTION: Individuals with diabetes are at increased risk for complications, including gastroparesis. Type 1 diabetes mellitus (T1DM) is an autoimmune disorder resulting in decreased beta-cell function. Glutamic acid decarboxylase-65 antibody (GADA) is the most commonly used test to assess autoimmunity while C-peptide level is used to assess beta-cell function. Patients with type 2 diabetes mellitus (T2DM), who are GADA positive, are labeled latent autoimmune diabetes in adults (LADA). OBJECTIVE: To characterize patients with T1 and T2DM who have symptoms of gastroparesis using GADA and C-peptide levels and to look for association with the presence of gastroparesis and its symptom severity. DESIGN: 113 T1DM and 90 T2DM patients with symptoms suggestive of gastroparesis were studied. Symptom severity was assessed using Gastroparesis Cardinal Symptom Index (GCSI). Serum samples were analyzed for GADA and C-peptide. RESULTS: Delayed gastric emptying was present in 91 (81%) of T1DM and 60 (67%) of T2DM patients (p = 0.04). GADA was present in 13% of T2DM subjects [10% in delayed gastric emptying and 20% in normal gastric emptying (p = 0.2)]. Gastric retention and GCSI scores were mostly similar in GADA positive and negative T2DM patients. GADA was present in 45% of T1DM subjects [46% in delayed gastric emptying and 41% in normal gastric emptying (p = 0.81)]. Low C-peptide levels were seen in 79% T1DM patients and 8% T2DM. All seven T2DM patients with low C-peptide were taking insulin compared to 52% of T2DM with normal C-peptide. CONCLUSION: GADA was present in 13% while low C-peptide was seen in 8% of our T2DM patients with symptoms of gastroparesis. Neither did correlate with degree of delayed gastric emptying or symptom severity. CLINICALTRIALSGOV IDENTIFIER: NCT01696747.

Circulating tissue factor procoagulant activity and thrombin generation in patients with type 2 diabetes: effects of insulin and glucose.

CONTEXT: Type 2 diabetes mellitus (T2DM) is a hypercoagulable state. Tissue factor (TF) is the principal initiator of blood coagulation. OBJECTIVE: Our objective was to examine the effects of hyperglycemia and hyperinsulinemia on the TF pathway of blood coagulation in T2DM. DESIGN: Three study protocols were used: 1) acute correction of hyperglycemia (with iv insulin) followed by 24 h of euglycemia, 2) 24 h of selective hyperinsulinemia, and 3) 24 h of combined hyperinsulinemia and hyperglycemia. SETTING: The study took place at a clinical research center. STUDY PARTICIPANTS: Participants included 18 T2DM patients and 22 nondiabetic controls. RESULTS: Basal TF-procoagulant activity (TF-PCA), monocyte TF mRNA, plasma coagulation factor VII (FVIIc), and thrombin-anti-thrombin complexes were higher in T2DM than in nondiabetic controls, indicating a chronic procoagulant state. Acutely normalizing hyperglycemia over 2-4 h resulted in a small ( approximately 7%) but significant decline in TF-PCA with no further decline over 24 h. Raising insulin levels alone raised TF-PCA by 30%, whereas raising insulin and glucose levels together increased TF-PCA (by 80%), thrombin-anti-thrombin complexes, and prothrombin fragment 1.2. Plasma FVIIa and FVIIc declined with increases in TF-PCA. CONCLUSION: We conclude that the combination of hyperglycemia and hyperinsulinemia, common in poorly controlled patients with T2DM, contributes to a procoagulant state that may predispose these patients to acute cardiovascular events.

Effects of hyperglycemia and hyperinsulinemia on circulating tissue factor procoagulant activity and platelet CD40 ligand.

Individuals with chronically elevated glucose and/or insulin levels, i.e., most patients with type 2 diabetes, have accelerated atherosclerosis and are prone to acute vascular events. We have tested the hypothesis that hyperglycemia and/or hyperinsulinemia singly or combined may increase tissue factor, the primary initiator of blood coagulation. We have determined changes in circulating tissue factor procoagulant activity (PCA) and other procoagulation proteins in healthy volunteers exposed to 24 h of selective hyperinsulinemia, selective hyperglycemia, or combined hyperinsulinemia and hyperglycemia. Combined elevations of plasma insulin and glucose levels for 24 h produced a ninefold increase in tissue factor PCA, which was associated with an increase in monocyte tissue factor protein (flow cytometry) and mRNA (RT-PCR), increases in plasma thrombin-antithrombin complexes, prothrombin fragment 1.2, factor VIII coagulant activity, and platelet CD40 ligand as well as decreases in factor VIIa, factor VII coagulant activities, and factor VII antigen. Effects of selective hyperinsulinemia and selective hyperglycemia were less striking but appeared to be additive. We conclude that hyperinsulinemia and hyperglycemia but particularly the combination of both create a prothrombotic state and in addition may be proinflammatory and proatherogenic because of the proinflammatory actions of CD40 ligand and tissue factor.

Use of an internet-based telemedicine system to manage underserved women with gestational diabetes mellitus.

BACKGROUND: Internet technology has been proven to be a successful tool for the management of patients with multiple medical conditions. The purpose of this study was to demonstrate the feasibility of monitoring glucose control in indigent women with gestational diabetes mellitus (GDM) over the Internet. METHODS: Women with GDM were randomized to either the Internet group (n = 32) or the control group (n = 25). Patients in the Internet group were provided with computers and/or Internet access if needed. A website was established for documentation of glucose values and communication between the patient and the health care team. Women in the control group maintained paper logbooks, which were reviewed at each prenatal visit. Maternal feelings of diabetes self-efficacy were assessed at study entry and again before delivery. RESULTS: Women in the Internet group accessed the system and sent on average 21.8 (+/- 16.9) sets of data. There was no difference between the two groups in regards either fasting or post-prandial blood glucose values, although more women in the Internet group received insulin therapy (31% vs. 4%; P <0.05). There were also no significant differences in pregnancy and neonatal outcomes between the two groups. Women in the Internet group demonstrated significantly higher feelings of self-efficacy at the study's end. CONCLUSIONS: The benefit of monitoring blood glucose in indigent women with GDM via the Internet was limited by their infrequent use of the telemedicine system. Although system use was not associated with improved pregnancy outcomes, women in the telemedicine group did experience enhanced feelings of diabetes psychosocial self-efficacy.

Methods of measuring insulin sensitivity.

Insulin resistance is a component of several health disorders, most notably impaired glucose tolerance and type 2 diabetes mellitus. Insulin-resistant individuals have an impaired biological response to the usual action of insulin; that is, they have reduced insulin sensitivity. Various methods are used to assess insulin sensitivity both in individuals and in study populations. Validity, reproducibility, cost, and degree of subject burden are important factors for both clinicians and researchers to consider when weighing the merits of a particular method. This article describes several in vivo methods used to assess insulin sensitivity and presents the advantages and disadvantages of each.