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Biomedical subjects

R Mazze

Publications and source records attributed to R Mazze.

At least 19 recordsLinked to original sources
PubMed1998

Staged diabetes management: computerizing a disease state management program.

Recently, the Diabetes Control and Complication Trial (DCCT) and other similar studies have demonstrated that near-normalization of blood glucose in diabetes will reduce complications up to 75% but translation of these results into practice has been difficult. In an attempt to help provide the best possible control of patients with diabetes, we have produced an attempt to help provide the best possible control of patients with diabetes, we have produced a new disease state management system for diabetes, called "Staged Diabetes Management" (SDM), implemented it in over 100 sites worldwide, and developed a computer program to simplify its use. SDM, designed to change the way we deal with patients with diabetes, is based upon five principles: (1) community involvement in setting care guidelines; (2) negotiation of goals with patients; (3) appropriate timelines for therapeutic success; (4) use of flowcharts for medical decisions; and (5) evaluation of the program. SDM is designed to be altered by a community to meet its needs and resources. It encourages primary care physicians to deliver better diabetes care using a team approach and to refer patients with diabetes to specialists when appropriate. It has a complete set of materials for communities, individual health care providers and patients. SDM has been tested for changes in structure, process and outcomes. A meta-analysis of seven clinical trials with over 500 patients has shown a time-weighted average fall in hemoglobin A1c of 1.7 points (equivalent to a drop in mean blood glucose of about 3.5 mM or 60 mg/dL). Preliminary pharmacoeconomic analysis demonstrates a lifetime cost saving of over $27,000 per patient. A computer program has been developed for the Microsoft Windows environment that contains a client-server database, based upon DiabCare, for the data file structure.

Adult↗
PubMed1998

Reducing lower-extremity amputations due to diabetes. Application of the staged diabetes management approach in a primary care setting.

BACKGROUND: While lower-extremity amputation (LEA) is a frequent complication of diabetes, effective strategies for the prevention of LEA in primary care settings have not been extensively studied. METHODS: This prospective study of American Indians with diabetes in a rural primary care clinic was divided into three periods: the standard care period (1986 to 1989), during which patients received foot care at the discretion of the primary care provider; the public health period (1990 to 1993), during which patients were screened for foot problems and high-risk individuals received foot care education and protective footwear; and the Staged Diabetes Management (SDM) period (1994 to 1996), during which comprehensive guidelines for diabetic foot management were adapted by the primary care clinicians to their practices and were systematically implemented. RESULTS: A total of 639 individuals contributed 4322 diabetic person-years during the three periods of observation. Patient sex distribution, mean age, and mean duration of diabetes were similar i the three periods. The average annual LEA incidence was 29/1000 diabetic person-years for the standard care period (n = 42), 21/1000 for the public health period (n = 33), and 15/1000 for the SDM period (n = 20), an overall 48% reduction (P = .016). Overall, the incidence of a first amputation declined from 21/1000 to 6/1000 (P < .0001). CONCLUSIONS: The customization and systematic implementation of practice guidelines by local primary care providers was associated with improved diabetic foot care outcomes. SDM has relevance to primary care organizations seeking to improve outcomes for patients with diabetes.

Adult↗
PubMed1994

Comparison of home glucose monitoring with the oral glucose tolerance test to detect gestational glucose intolerance.

BACKGROUND: Recent evidence suggests that infant morbidity is increased among women who have abnormal prenatal glucose screening tests but who do not have gestational diabetes mellitus (GDM). These women fall into a diagnostic gray zone and historically have not been treated. METHODS: Forty-eight pregnant women with abnormal oral glucose challenge test results performed self-monitored blood glucose (SMBG) testing seven times per day for 1 week before undergoing a diagnostic 100-g oral glucose tolerance test (OGTT). At delivery, perinatal complications and birthweights were recorded. Results of SMBG tests for women with normal OGTTs were correlated with infant birthweights. RESULTS: Thirteen infants (37%) were found to be large for gestational age (LGA). Significant correlation was found between increasing birthweight and increasing average fasting SMBG values (P < .001), increasing percentage of SMBG values above 120 mg/dL (6.7 mmol/L) (P < .01), and increasing average SMBG values (P < .016). CONCLUSIONS: Maternal home glucose values at 28 weeks correlate with the risk of LGA infant births among women in the diagnostic gray zone. Women with average fasting SMBG values > 95 mg/dL (5.3 mmol/L) are at increased risk for giving birth to LGA infants and may be more likely to exhibit complications usually associated with GDM.

Birth Weight↗
PubMed1994

Clinical consequences of the Diabetes Control and Complications Trial.

The DCCT has settled the question of the relationship of diabetes control to diabetes complications. By utilizing intensive diabetes therapy, the DCCT was able to reduce the risk of diabetes complications by 50 to 75 percent. As practicing physicians, in the era of health care reform, we must devise methods to bring quality diabetes care to our patients with diabetes in a cost-effective manner. SDM is a system for providing this quality, cost-effective effective care for patients with diabetes.

Blood Glucose↗
PubMed1993

Glucose intolerance as a consequence of oral terbutaline treatment for preterm labor.

BACKGROUND: In this case series, glucose regulation is examined prospectively during treatment with terbutaline sulfate for premature labor in women who were (1) previously documented as nondiabetic, (2) found to have gestational diabetes mellitus (GDM), and (3) tested for glucose intolerance while terbutaline was being administered. The glucose profiles of women treated with terbutaline were contrasted with the profiles of nondiabetic women and women known to have GDM who were not in premature labor. METHODS: Subjects tested capillary blood glucose an average of five times a day during terbutaline treatment and for 1 week after terbutaline treatment was discontinued. They used memory-based reflectometers that stored and transmitted self-monitored blood glucose data to a personal computer. RESULTS: A significant difference (P = .001) was found between average fasting glucose values (111 +/- 23 mg/dL) for the five nondiabetic subjects treated with terbutaline and values of patients in an historical control group (41 nondiabetic pregnancies [72 +/- 22 mg/dL]) who were not in premature labor. The four diabetic subjects and the one subject who had not been previously tested also experienced higher blood glucose levels during tocolytic therapy. Glucose levels returned to preintervention values with the cessation of terbutaline therapy. CONCLUSIONS: It has been previously suggested that terbutaline increases hepatic glycogenolysis, which may aggravate glucose intolerance. This phenomenon, combined with normal pregnancy-induced insulin resistance, may explain abnormal ambulatory glucose patterns in women who are euglycemic before introduction of terbutaline therapy.

Adult↗
PubMed1991

Rationale for insulin management in gestational diabetes mellitus.

A prospective study was undertaken to test the hypothesis that insulin treatment in patients with gestational diabetes mellitus (GDM) with fasting plasma glucose (FPG) greater than 5.3 mM significantly reduces adverse perinatal outcome. Assigned to insulin or diet treatment based on FPG were 471 GDM women. Four factors believed to be associated with infants large for gestational age (LGA) were evaluated: FPG, overall glycemic control, maternal weight, and treatment regimen. We found that when glycemic control was optimized, the key factors related to large infants were FPG and treatment modality. In the low-FPG group (less than 5.3 mM), diet therapy achieved an incidence of 5.3% LGA. When insulin therapy was used to optimize control, an incidence of 3.5% LGA was found. Patients in the mid-FPG group (5.3-5.8 mM) had a higher increased rate of LGA (28.6%) for diet-treated versus insulin-treated women (10.3%). In addition, a fourfold increased risk for LGA was found in the diet-treated obese subjects in the mid-FPG group compared with insulin-treated obese women. Finally, treatment with insulin resulted in similar incidence of LGA within all FPG groups. We concluded that FPG greater than 5.3 mM can be the basis for initiation of insulin treatment in GDM subjects with optimization of glycemic control as the goal. This approach may contribute significantly to reduced neonatal risk and may foster a standardized method for rapid and effective assignment to treatment.

Adult↗
PubMed1990

Enhancement by hyponatremia and hyperkalemia of ventricular conduction and rhythm disorders caused by bupivacaine.

Intraventricular conduction disorders and reentrant arrhythmias in dogs can be produced by high plasma bupivacaine concentrations. The authors' aim was to determine if these conduction disturbances also occurred at moderate plasma bupivacaine concentrations (2.2-3.7 micrograms/ml) when in association with other factors which affect intracardiac conduction, such as hyponatremia and hyperkalemia. Thus, duration of the QRS complex, ventricular conduction time, and effective refractory period (ERP) was measured during ventricular pacing at 180 beats per min in 46 anesthetized, closed-chest dogs separated into five treatment groups as follows: group I, an iv bolus of 4 mg/kg of bupivacaine plus an infusion of 0.1 mg.kg-1.min-1 of bupivacaine followed in 50-60 min by 10 ml.kg-1.min-1 of 1.5% glycine iv to produce dilutional hyponatremia; group II, 1.5% glycine alone, as above; group III, bupivacaine, as above, followed in 50-60 min by 0.05 mmol.kg-1.min-1 of KCl iv to produce hyperkalemia; group IV, KCl alone, as above; and group V, bupivacaine, as above, except that the duration of infusion was 90 min. QRS duration and ventricular conduction time, which were prolonged approximately 33% and 61%, respectively, by bupivacaine alone were additionally prolonged 29% and 44%, respectively, when serum sodium concentration was lowered to 114 mmol/l and potassium concentration was raised to 7.7 mmol/l. The combinations of bupivacaine and hyponatremia, and bupivacaine and hyperkalemia tended to increase ERP more than did bupivacaine alone, although these changes were not statistically significant. Wave burst arrhythmias and episodes of ventricular tachycardia occurred spontaneously or were triggered by pacing in those dogs in which conduction time was most prolonged.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1988

The relationship between large-for-gestational-age infants and glycemic control in women with gestational diabetes.

In this prospective study 246 women with gestational diabetes were followed up to determine the characteristics of metabolic control associated with large-for-gestational-age infants. Memory-based reflectance meters were used for self-monitoring blood glucose. Ambulatory glucose profiles were produced to characterize glycemic control levels throughout pregnancy. With these novel approaches to the collection and representation of glucose data, the severity of glucose intolerance (hyperglycemia) was found to be associated with both maternal and neonatal morbidity in terms of infant size and cesarean section rate. By use of hierarchical cluster analysis to identify three groups on the basis of control levels (low less than 87 mg/dl, mid 87 to 105 mg/dl, high greater than 105 mg/dl) we were able to show a positive outcome in the low group with reduced rates of large-for-gestational-age (2%) and macrosomatic (0%) infants. Furthermore, we showed that as mean blood glucose levels and instability in glycemic control increased from group to group, incidence of large-for-gestational-age and macrosomatic infants increased. Whereas obesity increased the relative risk of adverse neonatal outcome, type of treatment (insulin versus diet) did not appear to be significant. Appropriately monitored toward stability within a narrow range to achieve tight metabolic control, ambulatory glycemia in pregnancy is associated with a decreased risk of maternal and fetal complications.

Blood Glucose↗
PubMed1988

Pregestational diabetes: insulin requirements throughout pregnancy.

The management of pregestational diabetes requires tight metabolic control to reduce maternal and perinatal morbidity and mortality. It has been suggested that type I diabetes is a disorder characterized by insulin deficiency and type II diabetes is characterized by insulin resistance; however, it may be hypothesized that a difference in insulin requirements should emerge throughout pregnancy to reflect the dissimilarities in these two metabolic disturbances. The current investigation of 103 women with pregestational diabetes used a novel approach (reflectance meters with onboard memories) to uncover the actual insulin dosages required to reach and maintain optimum metabolic control throughout pregnancy. It was found that both type I and type II diabetes appear to have a triphasic insulin pattern, with the patient having type II diabetes requiring significantly higher doses of insulin during each trimester. This seems to suggest that the hormonal changes in pregnancy may have a similar effect on both type I and type II diabetes but to a different degree. Thus this should be considered in the treatment of pregestational diabetes and in the development of an algorithm for diabetes management.

Adult↗
PubMed1987

Gestational diabetes: insulin requirements in pregnancy.

A prospective study of 57 women with gestational diabetes mellitus was undertaken to determine actual insulin requirements throughout pregnancy. Women were placed on a multiple injection, mixed insulin regimen and monitored their blood glucose level 6.5 +/- 1 times per day using a memory-based reflectance meter to obtain verified data. A significant (p less than 0.01) increase in total insulin dose was found during the initial treatment period (7 +/- 2 days) until the target glucose range was achieved. Insulin requirements continued to significantly (p less than 0.01) rise until 30 +/- 1 gestational weeks, despite a stabilization of glucose level. Thereafter, there was no significant change (3%) in insulin requirement. A correlation of r = 0.58 (p less than 0.001) for the relationship between insulin dose at the 24 and 32 weeks' gestation, and an r = 0.99 (p less than 0.0001) for the relationship between insulin dose at 32 and 39 weeks' gestation was found. We concluded that an emphasis on ambulatory blood glucose control and insulin adjustments should occur in the early treatment phase of gestational diabetes.

Adult↗
PubMed1987

Verified self-monitored blood glucose data versus glycosylated hemoglobin and glycosylated serum protein as a means of predicting short- and long-term metabolic control in gestational diabetes.

Glycosylated hemoglobin and glycosylated serum protein have been suggested as tools for evaluation of long- and short-term glycemic control, respectively. Twenty-six patients with gestational diabetes were prospectively studied to determine the relationship of glycosylated hemoglobin and glycosylated serum protein to metabolic control. To verify the accuracy of blood glucose data, a memory-based reflectance meter was used for subjects with gestational diabetes who tested 6.5 +/- 1 times per day. Our analysis revealed that despite a statistically positive correlation between glycosylated hemoglobin, glycosylated serum protein, and verified data, their use as a clinical tool is limited because of their poor predictability.

Adult↗
PubMed1987

The significance of one abnormal glucose tolerance test value on adverse outcome in pregnancy.

A matched control study of 126 women equally divided into three groups (normal oral glucose tolerance test, one abnormal test value, and gestational diabetes mellitus) was undertaken to examine the relationships among oral glucose tolerance test results, glycemic control in pregnancy, and adverse perinatal outcome. Characterization of metabolic control for the one abnormal oral glucose tolerance test value and the gestational diabetes mellitus groups (before treatment) showed no significant difference. After the start of treatment, however, a significant (p less than 0.01) difference between the groups in level of control was found. While no significant difference in the average birth weight between the three groups was discovered, the incidence of large infants (macrosomia and large for gestational age) was found to be significantly higher in the one abnormal oral glucose tolerance test group when compared with the normal (34% versus 9%; p less than 0.01) and gestational diabetes mellitus group (34% versus 12%; p less than 0.01). No significant difference for the incidence of an infant large for gestational age was found between the normal group and the patients with gestational diabetes mellitus after treatment. Neonatal metabolic disorders were found to be significantly higher for the one abnormal oral glucose tolerance test group (15%) when compared with the control and the gestational diabetes mellitus groups (3%). We conclude that, if left untreated, one abnormal value on an oral glucose tolerance test is strongly associated with adverse perinatal outcome.

Adult↗
PubMed1986

Assessment of long-term glycemia in type I diabetes using multiple blood glucose values stored in a memory-containing reflectometer.

The relationship between repetitive hemoglobin A1 values and daily blood glucose tests performed by 20 insulin-dependent diabetic outpatients was assessed over a six-week period using a modified reflectance meter capable of storing blood glucose determinations automatically. An average of four and a half determinations per subject per day was recorded with a range of average blood glucose values between 82 +/- 2 mg/dl and 316 +/- 5 mg/dl (mean +/- SE). The relationship between average blood glucose and hemoglobin A1 values was significant when hemoglobin A1 values at the end of the six-week period were correlated with the mean blood glucose level over that period (r = 0.55, p less than 0.02), but improved when a more remote hemoglobin A1 value obtained at 10 weeks was used (r = 0.64, p less than 0.005). Hemoglobin A1 values covering two-week intervals were extremely poor in reflecting average glycemia. The average fasting blood glucose level in these subjects was highly correlated with the overall daily blood glucose values (r = 0.89, p less than 0.0001), although the coefficients of variation of these parameters averaged 43 +/- 3 percent and 47 +/- 2 percent, respectively, and were greater than that of the hemoglobin A1 values over six weeks (10 +/- 2 percent). It is concluded that labile blood glucose control in patients with insulin-dependent diabetes is accurately reflected by the average fasting blood glucose level, although multiple determinations must be employed. Satisfactory assessment may be made by use of hemoglobin A1 value provided that the hemoglobin A1 determination follows a sufficiently long period of time, presumably related to the turnover of glycosylated hemoglobin.

Blood Glucose↗
PubMed1983

Thymidine and methionine syntheses in pregnant rats exposed to nitrous oxide.

The dose-dependent effects of nitrous oxide on thymidine and methionine syntheses were investigated in pregnant rats. Female Sprague-Dawley rats were exposed on day 9 of gestation to 0.75%, 7.5%, or 75% nitrous oxide for 24 h. Immediately and 72 h after exposure, a deoxyuridine-suppression test was performed on maternal bone marrow and a methionine synthetase assay was performed on maternal liver to assess thymidine and methionine syntheses, respectively. Inhibition of thymidine synthesis was seen after exposure to 7.5% and 75%, but not after 0.75%, nitrous oxide. Recovery was complete 72 h after exposure. Methionine synthetase activity was abolished at all concentrations of nitrous oxide tested and did not return to control values 72 h after exposure. Fetal weight and gross appearance were not affected by exposure to nitrous oxide; however, the observed decrease in thymidine and methionine syntheses after nitrous oxide exposure may account for its teratogenic effects.

5-Methyltetrahydrofolate-Homocysteine S-Methyltran↗
PubMedDate not supplied

Professional education in a long-term-care facility: program development in diabetes.

To effect diabetes care in a 1000-bed chronic care institution, a program development approach to multidisciplinary staff education was implemented. Chart audit, staff interviews, and observations were used to evaluate care standards. Initial assessment revealed that none of the charts included a thorough evaluation of patients for skills, knowledge, and adherence related to care of diabetes. Additionally, it was found that the current diagnostic criteria for diabetes and urine testing procedures were not being used. An educational approach was implemented to teach current information about diabetes, to focus on multidisciplinary coordination of care, and to set goals for care on model care units. Postintervention assessments of the model care units were completed at 6 and 24 mo. There were substantial alterations in care, with more of the charts meeting the standard in each of the eight categories under investigation: diabetes diagnosis according to National Diabetes Data Group criteria, urine testing, capillary blood testing, rotation of insulin injection site, assessment of patients for adherence to regimen, assessment of patient skills and knowledge, and interdisciplinary coordination of care.

Cost-Benefit Analysis↗