The Diabetes Education Study: a controlled trial of the effects of intensive instruction of internal medicine residents on the management of diabetes mellitus.

The Diabetes Education Study was a controlled trial of the effects of physician and patient education. This article describes an educational program for internal medicine residents and its effects on ambulatory diabetes management practices. Forty-five of 86 residents practicing in the general medicine clinic of a university-affiliated city/county hospital were assigned randomly to receive a multifaceted program intended to 1) provide specific care recommendations, 2) teach necessary skills, and 3) make the professional and institutional environment more supportive. During the subsequent 11 months, 323 diabetic patients were interviewed and their records audited for evidence of changes in care. Experimental residents utilized fasting blood glucose determinations more often than controls (i.e., during 40% of visits vs. 31%, p = 0.004). Experimental residents also engaged more frequently in a variety of recommended dietary management recommendations. Isolated differences in monitoring/management of chronic complications also were found (e.g., lipid screening: 70% of experimental residents' patients vs. 58%, p = 0.016). Intensive, multifaceted programs of this nature are concluded to result in improvements in diabetes care, over and above that which is attainable through routine methods of clinical training for residents.

DIABEDS: a randomized trial of the effects of physician and/or patient education on diabetes patient outcomes.

To examine the effects of intensive patient and/or physician diabetes education on patient health outcomes, a controlled trial was conducted in which internal medicine residents and their 532 diabetic patients were randomly assigned to: routine care; patient education; physician education; or both patient and physician education. Patient outcome data were analyzed either by analysis of covariance on post intervention values (2-hour post-prandial plasma glucose [PPG]; body weight [BW]; blood pressure [BP]; or analysis of variance conducted on change values (fasting plasma glucose [FPG] and glycosylated hemoglobin [A1Hgb]). After patient education, significant improvements were observed in FPG, A1Hgb, BW, and systolic and diastolic BP. Physician education resulted in significant decreases in FPG, A1Hgb and BW. The combination of patient plus physician education resulted in the greatest improvements in patients' health outcomes including FPG, A1Hgb, PPG, BW and diastolic BP. Adjusted systolic BPs were not significantly different in the two groups. While these physiologic improvements were statistically and probably clinically significant, hyperglycemia and obesity still persisted. Thus, achieving optimal patient outcomes for a chronic disease like diabetes mellitus may require a greater or more effective use of resources than currently estimated.

Diabetic foot infections. Bacteriologic analysis.

Diabetic patients with foot infections were prospectively evaluated over a two-year period. Cultures from reliable specimens avoiding contamination with foot ulcers were obtained in 54 infectious episodes. Staphylococcus species, Enterococcus species, Corynebacterium species, and various species of Enterobacteriaceae were commonly isolated. Common anaerobic isolates included Peptostreptococcus magnus, Peptostreptococcus prevotii, and Bacteroides species. Results of cultures from 94 unreliable specimens were similar. Results of reliable and unreliable specimens obtained simultaneously in 26 patients agreed in seven (27%), but antibiotics selected for organisms isolated from unreliable specimens would have adequately covered pathogens found in the reliable culture in 24 (93%). Diabetic foot infections usually involve mixed bacterial flora, including aerobic, facultatively anaerobic, and anaerobic microorganisms. Specimens should be obtained from infected tissue that does not communicate directly with the foot ulcer if possible. If such specimens are not available, cultures of purulent exudate within the foot ulcer or soft-tissue sinuses may provide useful information on which to base decisions about antibiotic therapy. Broad-spectrum beta-lactam antibiotics or a combination of antibiotics active against facultatively anaerobic cocci and bacilli as well as anaerobes provide the best empirical antimicrobial coverage in these patients.

Progression of atherosclerosis in diabetics.

Two hundred seventy-four diabetic patients were studied over a 2-year period to evaluate the progression of lower extremity atherosclerotic occlusive disease (ASO). At initial evaluation, ASO was noted in 98 patients (36%). Incidence of new or more severe disease was noted in 92 patients (34%) at follow-up. Increased age, longer duration of diabetes, lower percent ideal body weight, elevated systolic blood pressure, and elevated serum cholesterol levels were all significantly associated with disease progression. Patients with disease progression were found to have significantly lower nerve motor velocities and sensory conduction, higher serum creatinine levels, and a higher prevalence of retinopathy, proteinuria, and carotid artery disease (perhaps indicating concomitant neuropathy and microvascular disease). Diastolic pressure, race, fasting and postprandial glucose, fasting and postprandial insulin, fasting and postprandial C peptides, and glycosylated hemoglobin levels did not correlate with disease progression. The strongest prognostic indicator of disease progression appeared to be preexisting disease. Significant disease progression over a relatively short period indicates that treatment of the diabetic patients who have symptoms should be early and aggressive.

Diabetes mellitus and cerebrovascular disease: prevalence of carotid artery occlusive disease and associated risk factors in 482 adult diabetic patients.

The prevalence of carotid artery occlusive disease (CAOD) in a population of adults with diabetes mellitus was determined, and factors associated with its presence were identified. By oculoplethysmography and phonoangiography, 20% of the population studied had detectable CAOD. Univariate analyses revealed that patients with CAOD had a higher prevalence of retinopathy proteinuria, a slower mean conduction velocity in two of three nerves tested, and more atherosclerosis in the leg arteries. Furthermore, increased age, higher cholesterol, lower fasting insulin, higher systolic blood pressure, and less adiposity were associated with the presence of CAOD. Sex, race, type of diabetes (type I or II), duration of diabetes, and measures of glycemia were not related to CAOD. When 10 variables were analyzed by multivariate methods, higher systolic blood pressure, higher cholesterol, and reduced adiposity were found to be the combination most significantly related to CAOD.