Syndrome of lipodystrophy, hyperlipidemia, insulin resistance, and diabetes in treated patients with human immunodeficiency virus infection.

OBJECTIVE: To describe the syndrome of lipodystrophy, hyperlipidemia, insulin resistance, and diabetes in patients with human immunodeficiency virus (HIV) infection treated with protease inhibitor drugs. METHODS: This is a case series of patients referred from an infectious disease clinic to a diabetes-endocrinology clinic in an academic medical center because of severe metabolic problems that occurred during the course of otherwise-successful treatment of HIV infection. The clinical course, abnormalities on physical examination, laboratory data, and complications are described and analyzed. The pathogenesis of the syndrome is discussed and compared with that of type 2 diabetes, lipoatrophic diabetes, and mouse models of lipodystrophy. RESULTS: In six male patients receiving antiretroviral therapy for HIV infection, a syndrome of lipoatrophy of the face, legs, and buttocks, hyperlipidemia (predominantly hypertriglyceridemia), and type 2 diabetes mellitus was noted. Two patients had pronounced abdominal obesity, in contrast to their thin extremities. Five of the six patients were receiving protease inhibitor drugs, which have been thought to contribute to metabolic abnormalities. In two patients, ischemic heart disease had developed. CONCLUSION: Protease inhibitors frequently cause insulin resistance and lipoatrophy in subcutaneous adipose tissue. These abnormalities are associated with visceral adiposity, hyperlipidemia, diabetes, and cardiovascular consequences and represent an important and unsolved problem in the treatment of HIV-infected patients.

Overcoming turf battles: developing a pragmatic, collaborative model to improve glycemic control in patients with diabetes.

BACKGROUND: Collaboration between primary care physicians (PCPs) and endocrinologists should be the first step in improving care of patients with diabetes. However, the coordination of care between specialists and PCPs often does not work well. At Vanderbilt University Medical Center, a collaborative model between PCPs and endocrinology was used in an effort to improve glycemic control for patients with diabetes. METHODS: In 1998 a project team was formed; the team members attempted to find ways to improve the care of patients with diabetes, specifically patients with poor glycemic control. The team proceeded through ten iterations of the model before reaching one accepted by all-one with clear responsibilities and referral criteria. RESULTS: Survey results indicated a high level of satisfaction with the collaborative model among patients and PCPs. Appropriate referrals to the diabetes improvement program--a 12-week outpatient program consisting of instruction and support in diabetes self-management coupled with adjustment of insulin and oral hypoglycemic medications-increased during the team effort, and a control chart indicated a change in the process that was significant and sustained. The patients enrolled in the program experienced a reduction of mean glycated hemoglobin levels from 9.2% at entry to 7.5% after 3 months (p < 0.05). DISCUSSION: An initial first step to improving care is to create an environment of trust and collaboration between the PCPs and specialists who assist in that care. After this collaboration has been established, many of the improvements identified in other studies can more easily be implemented.

Newly identified hyperglycemia among hospitalized patients.

BACKGROUND: Earlier diagnosis and treatment of diabetes mellitus is desirable. We studied the prevalence of newly identified diabetes among hospital inpatients. METHODS: We did a prospective observational study in a community teaching hospital. RESULTS: Thirty-six patients had hyperglycemia on at least 2 days and were considered to have newly identified diabetes mellitus. They represented approximately 1% of the inpatient population. Sixteen (44%) were receiving corticosteroid treatment. Five of the patients (14%) died during the hospitalization. Twenty-four (67%) received insulin treatment during hospitalization. Of the 31 surviving patients, only 15 (48%) had documentation of discharge plans for diabetes-related treatment, 7 (23%) received instruction by a dietitian, and 5 (16%) received education about diabetes self-management from a diabetes nurse educator. CONCLUSION: Hospitalized patients with newly identified hyperglycemia represent an opportunity for early diagnosis, education, and treatment of a substantial proportion of patients with undiagnosed diabetes.

Hospitalization of patients with diabetes.

To determine annual hospitalization rates for patients with diabetes mellitus, we retrospectively analyzed the frequency of hospitalization among 905 patients with diabetes receiving primary care in a private practice outpatient program during a 20-month period (1,508 patient-years). We assessed the annual hospitalization rates stratified by diabetes clinical severity index, type of diabetes, type of treatment, age, sex, and mean glycosylated hemoglobin. The all-cause annual hospitalization rate was 211 per 1,000 patients (95% confidence interval, 184 to 238). Hospitalization rates were strongly correlated with measures of clinical severity; hospitalization rates did not vary significantly with type of diabetes, age, or sex. Among patients with type II diabetes, rates were higher in the group treated with insulin. A trend was noted for hospitalization rates to increase with mean glycosylated hemoglobin (not statistically significant in this sample). Overall, 14% of hospitalizations were for metabolic reasons, 45% were related to clinical complications of diabetes, and 41% were unrelated to the presence of diabetes. In analysis of hospitalization rates and therefore health-care expenditures for patients with diabetes, the characteristics of the patient population--and especially measures of clinical severity--must be considered. Interventions to reduce hospitalization can be targeted at high-risk groups.

The relationship between health beliefs, adherence, and metabolic control of diabetes.

There is evidence that an individual's health beliefs influence performance of health behaviors. The purpose of this study was to determine whether health beliefs in persons with diabetes could be modified during a clinical education program and whether the health beliefs were related to adherence to self-care instructions and metabolic control of diabetes. Health beliefs and HbA1c were measured at baseline in 189 adult outpatients with diabetes. Diabetes educators then attempted to modify health beliefs that were not conducive to positive health behaviors. Following education, some health beliefs were modified in a positive direction. Modest, but statistically significant increases in perceived severity of diabetes, perceived ability to carry out recommended behaviors, and perceived benefits of treatment were observed. Although HbA1c improved significantly in a subgroup of patients, this improvement could not be directly associated with any health belief or with self-reported adherence by the measures used in this study.

Dropout and relapse during diabetes care.

OBJECTIVE: To determine factors associated with dropout and relapse during chronic diabetes care. RESEARCH DESIGN AND METHODS: Private practice outpatient treatment-education program for adult diabetes was surveyed. Retrospective analysis was done, involving 422 patients for up to 3 yr. RESULTS: Of the patients in the study, 12% dropped out after the initial visit, and 33% of the residual cohort dropped out during each subsequent 6-mo period. Factors associated with dropout included distance from home to clinic > 100 miles, lack of insulin treatment, and cigarette smoking. In patients who remained in follow-up, a significant decrease in HbA1C occurred during the first 6 mo, but 40% of the patients relapsed between 6 and 12 mo. Frequency of relapse declined as time passed. Relapse was more frequent in women. CONCLUSIONS: Dropout from treatment and relapse after temporary improvement account for a substantial amount of uncontrolled diabetes, and overcoming the obstacles of dropout and relapse has potential for significant improvement in diabetes care.

Effects of intensified practitioner-patient communication on control of diabetes mellitus.

Control of diabetes mellitus requires active participation of patients in self-care and ongoing support from medical professionals. This study examines the hypothesis that control of diabetes can be improved by more frequent communication between patients and medical professionals. We instructed 233 insulin-requiring diabetic patients to mail the results of home blood glucose monitoring to the physician's office at least every two weeks. Feedback from office nurse practitioners followed receipt of these reports, providing frequent two-way communication between regularly scheduled office appointments. In the group of patients who mailed reports more than 26 weeks during the year, the mean glycosylated hemoglobin (GHb) value was 10.4% at baseline, and there was a mean decrease in GHb of 1.0% during the succeeding year (P = .001). In patients who mailed reports less than 26 weeks during the year, mean GHb was 10.2% at baseline, and there was no significant change during the succeeding year. Since mean GHb was virtually identical in the two groups at baseline, mailing the reports of home-determined blood glucose levels and receiving feedback between office visits resulted in improved control of diabetes.

Clinical characteristics of hospitalized diabetic patients.

In an inpatient diabetes control unit established to fulfill the special needs of hospitalized diabetic patients, 29% of the admissions were for control of diabetes. In 71% the metabolic abnormalities of diabetes were incidental to the cause of admission. Of the first 232 patients, 162 had type II diabetes. The degree of hyperglycemia in the type II patients was virtually identical to that in the type I patients, as measured by hemoglobin A1C levels at admission and by mean blood glucose values in the hospital. The mean hemoglobin A1C level at admission was 9.1% in both groups (normal 3.2 to 6.1). During hospitalization the patients admitted for medical and surgical problems achieved average blood glucose levels similar to levels in those who were admitted strictly for diabetes control. Regardless of the reason for admission, hospitalization of a diabetic patient is an opportunity for improvement in metabolic control and for patient education.

Planning for sex, marriage, contraception, and pregnancy.

PIP: Authors Graber, Christman and Boehm contend careful planning for marriage, contraceptive use and pregnancy is warranted when a chronic health problem such as diabetes is evident. Prospective mates should be fully aware of the problems and management of diabetes. Diabetic women who wish to delay pregnancy should consider using an effective contraceptive. It is suggested that the lowest dosage of oral contraceptive pill be used with full understanding of adverse side effects and agreement to discontinue their use if complications arise. IUDs can also be effectively used by diabetics. Sterilization should be considered if the woman has a 20 year history of diabetes, is older than 35 years or has diabetic vascular complications. Sterilization for male diabetic or mates of diabetic women is another option. Planning in regard to pregnancy should begin in the middle teens if a woman is diabetic. Pregnancy should be delayed until the following criteria are met: 1) Both partners should fully understand diabetes and its management; 2) Diabetes should be under control prior to pregnancy since it is likely to be aggravated by pregnancy; 3) Women should reach ideal body weight prior to pregnancy; 4) Pregnancy should be delayed 1 year after diagnosis of diabetes; 5) There should be an acceptance of additional difficulties associated with pregnancy; 6) Understanding the effects of diabetes on infants is crucial; and 7) Spouses should accept the possibility of greater health problems with diabetic mates when planning a family.^ieng

Coordinated metabolic and obstetric management of diabetic pregnancy.

Diabetes during pregnancy is associated with insulin resistance, an increase in insulin requirement, and a greater tendency to ketosis and ketoacidosis. Increased perinatal mortality is related to maternal hyperglycemia and can be decreased dramatically with strict control of plasma glucose during pregnancy and a smooth-working obstetrician-internist-neonatologist team. Bad prognostic signs include pyelonephritis, ketoacidosis, toxemia, and poor prenatal care. Timing of delivery is no longer arbitrary at 36 or 37 weeks, but is based upon signs of fetal lung maturation and estimates of fetal risk. Abnormalities in the infant, including congenital abnormalities, biochemical abnormalities, respiratory distress syndrome, and large body weight must be managed in a well-equipped newborn intensive care unit under the care of experienced neonatologists. Strict attention to these principles has resulted in viable infants in the last 36 pregnant diabetic patients delivered at Vanderbilt University Hospital. Therefore, close medical supervision, use of modern obstetric technics, and the availability of a well-equipped and staffed neonatal intensive care unit can result in a good outcome in this group of patients. Finally, the decision for pregnancy must be carefully considered by the diabetic patient, her husband, and her physician long before pregnancy occurs.