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Biomedical subjects

Irl B Hirsch

Publications and source records attributed to Irl B Hirsch.

At least 37 records · Page 2Linked to original sources
PubMed2003

Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review.

CONTEXT: Newer insulin therapies, including the concept of physiologic basal-prandial insulin and the availability of insulin analogues, are changing clinical diabetes care. The key to effective insulin therapy is an understanding of principles that, when implemented, can result in improved diabetes control. OBJECTIVE: To systematically review the literature regarding insulin use in patients with type 1 and type 2 diabetes mellitus (DM). DATA SOURCES: A MEDLINE search was performed to identify all English-language articles of randomized controlled trials involving insulin use in adults with type 1 or type 2 DM from January 1, 1980, to January 8, 2003. Bibliographies and experts were used to identify additional studies. STUDY SELECTION AND DATA EXTRACTION: Studies were included (199 for type 1 DM and 144 for type 2 DM, and 38 from other sources) if they involved human insulins or insulin analogues, were at least 4 weeks long with at least 10 patients in each group, and glycemic control and hypoglycemia were reported. Studies of insulin-oral combination were similarly selected. DATA SYNTHESIS: Twenty-eight studies for type 1 DM, 18 for type 2 DM, and 48 for insulin-oral combination met the selection criteria. In patients with type 1 DM, physiologic replacement, with bedtime basal insulin and a mealtime rapid-acting insulin analogue, results in fewer episodes of hypoglycemia than conventional regimens. Rapid-acting insulin analogues are preferred over regular insulin in patients with type 1 DM since they improve HbA1C and reduce episodes of hypoglycemia. In patients with type 2 DM, adding bedtime neutral protamine Hagedorn (isophane) insulin to oral therapy significantly improves glycemic control, especially when started early in the course of disease. Bedtime use of insulin glargine results in fewer episodes of nighttime hypoglycemia than neutral protamine Hagedorn regimens. For patients with more severe insulin deficiency, a physiologic insulin regimen should allow lower glycemic targets in the majority of patients. Adverse events associated with insulin therapy include hypoglycemia, weight gain, and worsening diabetic retinopathy if hemoglobin A1C levels decrease rapidly. CONCLUSIONS: Many options for insulin therapy are now available. Physiologic insulin therapy with insulin analogues is now relatively simple to use and is associated with fewer episodes of hypoglycemia.

Ambulatory Care↗
PubMed2003

The changing faces of diabetes.

As understanding about the pathophysiology of diabetes mellitus continues to evolve, it is important that its classification reflects the current state of knowledge. The eventual goal is that appreciation of the different forms of diabetes eventually will result in better treatment of hyperglycemia. Even more exciting is the fact that this appreciation is allowing us to enter the era of diabetes prediction and prevention. The current classification scheme of diabetes does not yet account for all of the types of diabetes seen in a typical diabetes clinic. Fig. 1 illustrates our current understanding of the pathophysiology of diabetes and separates the diabetes types into those used in the current classification scheme. Clearly, new classifications will be required as we learn more about the different types of diabetes.

Diabetes Mellitus↗
PubMed2003

Using an Internet comanagement module to improve the quality of chronic disease care.

BACKGROUND: Web-based applications have the potential to support the ongoing care needs of patients with chronic disease. At the University of Washington, a diabetes care module was developed, and the feasibility of allowing patients with type 2 diabetes to comanage their disease from home was pilot tested. METHODS: The disease management module consisted of five Web sites that enabled patients to access their electronic medical records; upload blood glucose readings; enter medication, nutrition, and exercise data into an online diary; communicate with providers by using clinical e-mail; and browse an education site with endorsed content. All data could be viewed by patients and providers in online trended displays that a nurse practitioner case manager used to review cases weekly. RESULTS: "Proof-of-concept" was demonstrated by the three pilot participants who were the module's most active users. For example, one newly diagnosed patient was started on an oral hypoglycemic, underwent two upward dose adjustments, and achieved control (glycohemoglobin [HbA1c] from 8.0% to 6.1%). His treatment was conducted by exchanging 14 e-mails based on the 231 glucose-meter readings sent from home without requiring in-person follow-up visits. CONCLUSIONS: The Internet offers the opportunity to involve patients and providers in collaborative management of chronic diseases between office visits.

Adult↗
PubMed2003

Visceral obesity, hepatic lipase activity, and dyslipidemia in type 1 diabetes.

Excessive weight gain in a subset of intensively treated Diabetes Control and Complications Trial (DCCT) subjects was associated with higher waist to hip ratio; higher triglyceride (TG), low-density lipoprotein (LDL) cholesterol, and apolipoprotein B (ApoB) in the presence of small-dense LDL; and decreased high-density lipoprotein 2 cholesterol (HDL2-C), suggesting that weight gain in these subjects resulted in higher intraabdominal fat (IAF), and an atherosclerotic dyslipidemia mediated through hepatic lipase activity (HL). Objectives were to investigate relationships between IAF, HL, and dyslipidemia and to relate IAF to previous body mass index change during the DCCT. Sixty-one subjects were studied approximately 4 yr after DCCT closeout. IAF was positively related to HL (P < 0.001). IAF positively correlated with logTG (P < 0.001) and ApoB (P < 0.001), and negatively with LDL relative flotation rate (P < 0.001) and logHDL2-C (P = 0.001). HL accounted for most of the relationship between IAF with logHDL2-C and LDL relative flotation rate, and none of the relationship between IAF and logTG or ApoB. DCCT-related body mass index change accounted for a significant portion of logIAF variance measured 4 yr later (P < 0.001). Elevated IAF in subjects with type 1 diabetes was related to an atherosclerotic dyslipidemia similar to that seen in individuals without diabetes who have metabolic syndrome. DCCT-related weight gain positively correlated with subsequent IAF.

Adipose Tissue↗
PubMed2003

The rationale and management of hyperglycemia for in-patients with cardiovascular disease: time for change.

There is increasing evidence that aggressive glycemic control for patients admitted into the hospital improves clinical outcomes, especially for patients with cardiovascular disease. There appear to be a variety of mechanisms for this. Although hyperglycemia has been shown to result in poor wound healing and more infectious complications, especially after cardiac surgical procedures, what has become clear is that the treatment of hyperglycemia with i.v. glucose, insulin, and potassium (GIK) results in better clinical outcomes even in patients without diabetes. The mechanisms for this are not year clear, but could be related to the insulin administration, perhaps due to suppression of various cytokines or free fatty acids. The practical use of insulin in these patients requires basic understanding of the use of both i.v. and s.c. insulin. Although there are several appropriate options for both of these routes of administration, it is critical that all caregivers involved in this population's care are knowledgeable about insulin strategies.

Cardiovascular Diseases↗
PubMed2003

Relationship of family history of type 2 diabetes, hypoglycemia, and autoantibodies to weight gain and lipids with intensive and conventional therapy in the Diabetes Control and Complications Trial.

Intensive therapy for type 1 diabetes results in greater weight gain than conventional therapy. Many factors may predispose to this greater weight gain, including improved glycemic control, genetic susceptibility to obesity, and hypoglycemia. To study this, relationships among family history of type 2 diabetes, frequency of severe hypoglycemia, beta-cell autoantibodies, and weight gain were examined in 1,168 subjects aged > or =18 years at baseline randomized to intensive and conventional therapy groups in the Diabetes Control and Complications Trial. With intensive therapy, subjects with a family history of type 2 diabetes had greater central weight gain and dyslipidemia characterized by higher triglyceride levels and greater cholesterol in VLDLs and intermediate-density lipoproteins compared with subjects with no family history. Neither the frequency of severe hypoglycemia nor positivity to GAD65 and insulinoma-associated protein 2 antibodies was associated with increased weight gain with either intensive or conventional therapy. These data support the hypothesis that increased weight gain with intensive therapy might be explained, in part, by genetic traits.

Adolescent↗
PubMed2003

Continuous subcutaneous insulin infusion and multiple daily injection therapy are equally effective in type 2 diabetes: a randomized, parallel-group, 24-week study.

OBJECTIVE: Compare the efficacy, safety, and patient satisfaction of continuous subcutaneous insulin infusion (CSII) therapy with multiple daily injection (MDI) therapy for patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 132 CSII-naive type 2 diabetic patients were randomly assigned (1:1) to CSII (using insulin aspart) or MDI therapy (bolus insulin aspart and basal NPH insulin) in a multicenter, open-label, randomized, parallel-group, 24-week study. Efficacy was assessed with HbA(1c) and eight-point blood glucose (BG) profiles. Treatment satisfaction was determined with a self-administered questionnaire. Safety assessments included adverse events, hypoglycemic episodes, laboratory values, and physical examination findings. RESULTS: HbA(1c) values decreased similarly for both groups from baseline (8.2 +/- 1.37% for CSII, 8.0 +/- 1.08% for MDI) to end of study (7.6 +/- 1.22% for CSII, 7.5 +/- 1.22% for MDI). The CSII group showed a trend toward lower eight-point BG values at most time points (only significant 90 min after breakfast; 167 +/- 48 vs. 192 +/- 65 mg/dl for CSII and MDI, respectively; P = 0.019). A total of 93% of CSII-treated subjects preferred the pump to their previous injectable insulin regimen for reasons of convenience, flexibility, ease of use, and overall preference. Safety assessments were comparable for both treatment groups. CONCLUSIONS: Insulin aspart in CSII therapy provided efficacy and safety comparable to MDI therapy for type 2 diabetes. Patients with type 2 diabetes can be trained as outpatients to use CSII and prefer CSII to injections, indicating that pump therapy should be considered when initiating intensive insulin therapy for type 2 diabetes.

Blood Glucose↗
PubMed2003

Novel insulins and strict glycemic control. Analogues approximate normal insulin secretory response.

Our ability to gain strict glycemic control in diabetes has improved with the introduction of novel insulins. New formulations, novel insulin molecules, and various methods of insulin delivery are able to more closely approximate the normal physiologic insulin response than conventional preparations. In this article, the authors review the development of insulin formulations and the pharmacology of currently available insulin molecules and those soon to be on the market.

Humans↗
PubMed2002

A multifaceted intervention in support of diabetes treatment guidelines: a cont trial.

OBJECTIVE: in an academic family practice clinic, we performed a controlled trial of a multifaceted intervention versus usual care for managing diabetes. Providers received didactic training and computerized compliance feedback to support staged diabetes management, an evidenced-based approach to diabetes care. RESEARCH DESIGN AND METHODS: one firm of the clinic practice received the intervention, the other served as the control group during a 14-month baseline period and a 14-month study period. HbA1(c) was the principal outcome measure. RESULTS: there was a significant 0.71% difference in change in HbA1(c) values between the intervention and control firms (P=0.02). The subgroup with the greatest improvement in HbA1(c) was those subjects who started the intervention with a HbA1(c) above 8%. The overall improvement in glycemic control could not be explained by differences in visit frequency or the aggressiveness of drug therapy. There were no changes in healthcare utilization or costs between the two firms. CONCLUSION: in an academic family practice clinic, a multifaceted intervention in support of diabetes treatment guidelines modestly improved glycemic control without incurring additional costs. The improvement was mostly due to mitigation of the natural deterioration in control usually seen. Further efforts are required to involve all patients in co-managing their diabetes.

Blood Pressure↗
PubMed2002

Evidence-based management: using serial firm trials to improve diabetes care quality.

BACKGROUND: The design of delivery systems that can truly conduct continuous quality improvement (CQI) as a routine part of clinical care provision remains a vexing problem. The effectiveness of the "computerized firm system" approach to chronic disease CQI was examined, with diabetes as the focus of a 5-year case study. METHODS: A large family medical center had been divided into two parallel group practices for reasons of efficiency. These frontline structures (also known as primary care "firms") were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups. Because all the required longitudinal data were contained in a computerized repository, it was possible to conduct these controlled "firm trials" in a matter of months at low cost. RESULTS: During a 3-year period, implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin (HbA1c) testing by 50% (p = 0.02) and reduced the number of diabetic patients inadequately controlled by 43% (p < 0.01). Following this outcome improvement, patients exhibited a 16% reduction in ambulatory visit rates (p = 0.04). The observed outcome improvement, however, was reversed during the subsequent 2 years, when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions. CONCLUSIONS: The processes and outcomes of diabetes care were improved, demonstrating that CQI and controlled trials are not mutually exclusive in moving toward the practice of evidence-based management. Health care systems can, by conducting serial firm trials, become learning organizations. CQI programs of all kinds will likely never flourish, however, until quality improvement and reimbursement mechanisms have become better aligned.

Adult↗
PubMed2002

Interpersonal predictors of HbA(1c) in patients with type 1 diabetes.

OBJECTIVE: Research suggests that increased collaboration and satisfaction in the patient-provider relationship is associated with better outcomes in patients with diabetes. In adults, an interpersonal style characterized by low trust of others and excessive self-reliance is known as "dismissing attachment style." We hypothesized that diabetic patients with dismissing attachment style, due to a decreased ability to collaborate with providers and others, would have significantly higher HbA(1c) levels than patients with secure attachment style. RESEARCH DESIGN AND METHODS: From 276 adult tertiary care patients with type 1 diabetes, we obtained mean HbA(1c) levels over the prior year and assessed patient attachment style, demographics, and clinical characteristics. We used chi(2) tests and logistic regression to determine whether attachment style was associated with HbA(1c) levels. RESULTS: We found that 62% of patients with dismissing attachment style had mean HbA(1c) levels >or=8% compared with 34% of patients with secure attachment style (P = 0.002). After adjusting for demographics, diabetes severity, medical comorbidity, and depression, dismissing attachment style remained significantly associated with HbA(1c) levels >or=8%, compared with secure attachment style (odds ratio 2.5, 95% CI 1.1-6.0). CONCLUSIONS: We have found that dismissing attachment style is associated with a higher risk for poor glycemic control. This has relevance from a population-based perspective because approximately 25% of the general population has a dismissing attachment style. Attachment style is easily measured using self-report instruments and may inform clinicians how to work with patients who are less engaged in the health care relationship.

Adult↗