Prospective Randomized Controlled Trial to Evaluate Effectiveness of Registered Dietitian–Led Diabetes Management on Glycemic and Diet Control in a Primary Care Setting in Taiwan

[[abstract]]OBJECTIVE- In this randomized controlled trial we evaluated the effect of registered dietitian-led management of diabetes on glycemic control and macronutrient intake in type 2 diabetic patients in primary care clinics in Taiwan and studied the association between changes in macronutrient intake and glycemic measures. RESEARCH DESIGN AND METHODS- We recruited 154 adult patients with type 2 diabetes and randomly assigned them to a routine care control group (n = 79) or a registered dietitian-led intervention group (n = 75) who received on-site diabetic self-management education every 3 months over 12 months. RESULTS- Over the 1-year period, neither the intervention group (n = 75) nor the control group (n = 79) had significant changes in A1C, whereas the intervention patients with poorly controlled baseline A1C (?7%) (n = 56) had significantly greater improvements in A1C and fasting plasma glucose than the control subjects (n = 60) (-0.7 vs. -0.2%, P = 0.034; - 13.4 vs. 16.9 mg/dl, P = 0.007) during the same period. We also found significant net interventioncontrol group differences in overall energy intake (-229.06 ± 309.16 vs. 56.10 ± 309.41 kcal/day) and carbohydrate intake (-31.24 ± 61.53 vs. 7.15 ± 54.09 g/day) (P < 0.001) in patients with poorly controlled A1C. Multivariable adjusted modeling revealed an independent association between changes in carbohydrate intake and A1C in the intervention group (n = 56; β = 0.10, SEM = 0.033, P = 0.004). CONCLUSIONS- On-site registered dietitian-led management of diabetes can improve glycemic control in patients with poorly managed type 2 diabetes in primary care clinics in Taiwan. A reduction in carbohydrate intake may improve glycemic status

Performance Scores in General Practice: A Comparison between the Clinical versus Medication-Based Approach to Identify Target Populations

CONTEXT: From one country to another, the pay-for-performance mechanisms differ on one significant point: the identification of target populations, that is, populations which serve as a basis for calculating the indicators. The aim of this study was to compare clinical versus medication-based identification of populations of patients with diabetes and hypertension over the age of 50 (for men) or 60 (for women), and any consequences this may have on the calculation of P4P indicators. METHODS: A comparative, retrospective, observational study was carried out with clinical and prescription data from a panel of general practitioners (GPs), the Observatory of General Medicine (OMG) for the year 2007. Two indicators regarding the prescription for statins and aspirin in these populations were calculated. RESULTS: We analyzed data from 21.690 patients collected by 61 GPs via electronic medical files. Following the clinical-based approach, 2.278 patients were diabetic, 8,271 had hypertension and 1.539 had both against respectively 1.730, 8.511 and 1.304 following the medication-based approach (% agreement = 96%, kappa = 0.69). The main reasons for these differences were: forgetting to code the morbidities in the clinical approach, not taking into account the population of patients who were given life style and diet rules only or taking into account patients for whom morbidities other than hypertension could justify the use of antihypertensive drugs in the medication-based approach. The mean (confidence interval) per doctor was 33.7% (31.5-35.9) for statin indicator and 38.4% (35.4-41.4) for aspirin indicator when the target populations were identified on the basis of clinical criteria whereas they were 37.9% (36.3-39.4) and 43.8% (41.4-46.3) on the basis of treatment criteria. CONCLUSION: The two approaches yield very "similar" scores but these scores cover different realities and offer food for thought on the possible usage of these indicators in the framework of P4P programmes

Identifying older diabetic patients at risk of poor glycemic control

BACKGROUND: Optimal glycemic control prevents the onset of diabetes complications. Identifying diabetic patients at risk of poor glycemic control could help promoting dedicated interventions. The purpose of this study was to identify predictors of poor short-term and long-term glycemic control in older diabetic in-patients. METHODS: A total of 1354 older diabetic in-patients consecutively enrolled in a multicenter study formed the training population (retrospective arm); 264 patients consecutively admitted to a ward of general medicine formed the testing population (prospective arm). Glycated hemoglobin (HbA1c) was measured on admission and one year after the discharge in the testing population. Independent correlates of a discharge glycemia ≥ 140 mg/dl in the training population were assessed by logistic regression analysis and a clinical prediction rule was developed. The ability of the prediction rule and that of admission HbA1c to predict discharge glycemia ≥ 140 mg/dl and HbA1c > 7% one year after discharge was assessed in the testing population. RESULTS: Selected admission variables (diastolic arterial pressure < 80 mmHg, glycemia = 143–218 mg/dl, glycemia > 218 mg/dl, history of insulinic or combined hypoglycemic therapy, Charlson's index > 2) were combined to obtain a score predicting a discharge fasting glycemia ≥ 140 mg/dl in the training population. A modified score was obtained by adding 1 if admission HbA1c exceeded 7.8%. The modified score was the best predictor of both discharge glycemia ≥ 140 mg/dl (sensitivity = 79%, specificity = 63%) and 1 year HbA1c > 7% (sensitivity = 72%, specificity = 71%) in the testing population. CONCLUSION: A simple clinical prediction rule might help identify older diabetic in-patients at risk of both short and long term poor glycemic control

Evaluation par scanner à 64 rangées de détecteurs des volumes de l'oreillette gauche et de l'auricule gauche au cours du cycle cardiaque (analyse du retentissement de différentes cardiopathies par rapport à des patients normaux)

POITIERS-BU Médecine pharmacie (861942103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Amylose systémique avec atteinte cardiaque (étude et comparaison des critères diagnostiques en IRM cardiaque et en échographie transthoracique)

L'amylose AL systémique est une maladie rare caractérisée par l'accumulation de dépôts extracellulaires de fibrilles amyloïdes dans différents organes. L'atteinte cardiaque grève le pronostic avec une survie estimée à 6 mois en l'absence de traitement d'où l'importance d'un diagnostic précoce. Objectif : Il s'agissait de comparer les paramètres IRM et échocardiographiques (ETT) évocateurs d'atteinte cardiaque et d'identifier des critères ETT permettant de mieux sélectionner les patients à adresser en IRM cardiaque. Matériel et méthodes : Etude rétrospective à propos de 23 patients d'âge moyen 68,9 ans atteints d'amylose systémique ayant bénéficié d'une ETT et d'une IRM cardiaque à la recherche d'une atteinte cardiaque de l'amylose. En ETT nous avons recueilli les mesures du SIV, de la PP, de la masse VG. Nous avons également analysé la déformation longitudinale par AFI. En IRM, nous avons étudié les volumes et la masse du VG , la FEVG et le réhaussement tardif. Résultats : En plus des critères classiques échographiques de la cardiopathie amyloïde nous avons mis en évidence une hypertrophie concentrique du VG pour laquelle la mesure de la paroi postérieure était significativement différente entre les 2 groupes avec p=0,04 (IC[1,1 - 4,1]). L'étude du GLS global ne permettait pas de discriminer les 2 groupes. La mesure du GLS segment par segment permettait de différencier précocement les 2 groupes avec une altération importante du GLS au niveau basal p=0,02 [-9,9 ;-0,9] et modérée au niveau médian p=0,01 [-8,7 ; -0,9] en faveur d'une atteinte amyloïde. L'IRM confirmait le diagnostic d'amylose cardiaque en présence d'un réhaussement tardif p< 0,0001 (IC[2,8 5,2]) et permettait d'affiner les critères morphologiques. Conclusion : L'association de l'échographie et de l'IRM semble donner d'excellents résultats pour la recherche d'une atteinte amyloïde en cas d'amylose systémique. Il reste donc à affiner les critères évocateurs d'atteinte cardiaque en échographie afin d'optimiser la sélection des patients devant ou non bénéficier d'une IRM cardiaque.POITIERS-BU Médecine pharmacie (861942103) / SudocSudocFranceF