Kathryn Evans Kreider

Effect of intensiveversus standard blood pressure treatment according to baseline prediabetes status: A post hoc analysis of a randomized trial

OBJECTIVE To determine whether the effects of intensive (<120 mmHg) compared with standard (<140 mmHg) systolic blood pressure (SBP) treatment are different among those with prediabetes versus those with fasting normoglycemia at baseline in the Systolic Blood Pressure Intervention Trial (SPRINT). RESEARCH DESIGN AND METHODS This was a post hoc analysis of SPRINT. SPRINT participants were categorized by prediabetes status, defined as baseline fasting serum glucose ≥100 mg/dL versus those with normoglycemia (fasting serum glucose <100 mg/dL). The primary outcome was a composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular causes. Cox regression was used to calculate hazard ratios for study outcomes with intensive compared with standard SBP treatment among those with prediabetes and normoglycemia. RESULTS Among 9,361 participants randomized (age 67.9 ± 9.4 years; 35.5% female), 3,898 and 5,425 had baseline prediabetes and normoglycemia, respectively. After a median follow-up of 3.26 years, the hazard ratio for the primary outcome was 0.69 (95% CI 0.53, 0.89) and 0.83 (95% CI 0.66, 1.03) among those with prediabetes and normoglycemia, respectively (P value for interaction 0.30). For all-cause mortality, the hazard ratio with intensive SBP treatment was 0.77 (95% CI 0.55, 1.06) for prediabetes and 0.71 (95% CI 0.54, 0.94) for normoglycemia (P value for interaction 0.74). Effects of intensive versus standard SBP treatment on prespecified renal outcomes and serious adverse events were similar for prediabetes and normoglycemia (all interaction P > 0.05). CONCLUSIONS In SPRINT, the beneficial effects of intensive SBP treatment were similar among those with prediabetes and fasting normoglycemia.

Transitioning Safely from Intravenous to Subcutaneous Insulin

The transition from intravenous (IV) to subcutaneous (SQ) insulin in the hospitalized patient with diabetes or hyperglycemia is a key step in patient care. This review article suggests a stepwise approach to the transition in order to promote safety and euglycemia. Important components of the transition include evaluating the patient and clinical situation for appropriateness, recognizing factors that influence a safe transition, calculation of proper SQ insulin doses, and deciding the appropriate type of SQ insulin. This article addresses other clinical situations including the management of patients previously on insulin pumps and recommendations for patients requiring glucocorticoids and enteral tube feedings. The use of institutional and computerized protocols is discussed. Further research is needed regarding the transition management of subgroups of patients such as those with type 1 diabetes and end-stage renal disease.

Diabetes Distress or Major Depressive Disorder? A Practical Approach to Diagnosing and Treating Psychological Comorbidities of Diabetes

The presence of major depressive disorder (MDD) in people with diabetes may be up to three times more common than in the general population. People with diabetes and major depressive disorder have worse health outcomes and higher mortality rates. Diabetes distress refers to an emotional state where people experience feelings such as stress, guilt, or denial that arise from living with diabetes and the burden of self-management. Diabetes distress has also been linked to worse health outcomes. There are multiple treatment options for MDD including pharmacotherapy and cognitive behavioral approaches. Providers treating patients with diabetes must be aware of the frequent comorbidity of diabetes, diabetes distress, and depression and manage patients using a multidisciplinary team approach. This article discusses the epidemiology, pathophysiology, and bi-directional relationship of diabetes and depression and provides a practical, patient-centered approach to diagnosis and management.

Diabetes Self-management Quality Improvement Initiative for Medically Underserved Patients.

The burden of diabetes is greater for minorities and medically underserved populations in the United States. An evidence-based provider-delivered diabetes self-management education intervention was implemented in a federally qualified health center for medically underserved adult patients with type 2 diabetes. The findings provide support for the efficacy of the intervention on improvement in self-management behaviors and glycemic control among underserved patients with diabetes, while not substantially changing provider visit time or workload.

Practical Approaches to Diagnosing, Treating and Preventing Hypoglycemia in Diabetes

Hypoglycemia in individuals with diabetes can increase the risk of morbidity and all-cause mortality in this patient group, particularly in the context of cardiovascular impairment, and can significantly decrease the quality of life. Hypoglycemia can present one of the most difficult aspects of diabetes management from both a patient and healthcare provider perspective. Strategies used to reduce the risk of hypoglycemia include individualizing glucose targets, selecting the appropriate medication, modifying diet and lifestyle and applying diabetes technology. Using a patient-centered care approach, the provider should work in partnership with the patient and family to prevent hypoglycemia through evidence-based management of the disease and appropriate education.

Development of an Innovative Endocrinology Training Program for Nurse Practitioners

BACKGROUND Nurse practitioners (NPs) have a critical role in meeting the growing demand for health care in the current complex health care system. The use of NPs in both primary care and specialty settings is expected to rise significantly by 2025 in response to increased demands and a shortage of physician providers. METHOD The Duke University School of Nursing, with funding from the Health Resource Services Administration, has implemented the first endocrinology specialty training program for primary care NP students. RESULTS The first in the country, this innovative, hybrid training program prepares primary care NP students to manage complex diabetes mellitus and general endocrine conditions. CONCLUSION Well-trained NPs can help meet the increased demands in primary care. This subspecialty certificate program provides a framework for other graduate nursing schools that are considering adding specialty content as a supplement to primary care training. [J Nurs Educ. 2018;57(8):506-509.].

Diabetes Self-management Training in a Virtual Environment

Diabetes self-management training (DSMT) improves diabetes health outcomes. However, low numbers of patients receive DSMT. Using virtual environments (VEs) for DSMT is an innovative approach to removing barriers for patients. The purpose of this paper is to describe the experience of health professionals and diabetes educators establishing and teaching DSMT in a VE, Diabetes LIVE© (Learning in Virtual Environments), and the implications for future use of VEs in DSMT. It was found that providing DSMT in a VE preserves real-time interaction between patients and educators. To facilitate ongoing patient learning and engagement, the DSMT curriculum was expanded beyond the core content as “Above and Beyond” topics. Using a VE for DSMT presents challenges and opportunities. Challenges include overcoming technological barriers and improving comfort levels to orient educators and patients to the functionality of the VE. Opportunities include overcoming barriers to reaching patients, particularly given the diabetes epidemic and relatively small number of diabetes educators. Using a VE also affords a simulated community for experiential learning. VEs may become powerful tools for diabetes and other health educators to reach patients. Ongoing education and support are vital to successful self-management of chronic disease.

Caring for women with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting reproductive-age women. PCOS causes hyperandrogenism and anovulation and increases the risk of multiple health conditions including infertility, diabetes mellitus, and cardiovascular disease. This article outlines current recommendations for diagnostic testing, treatment options, and holistic care of the woman with PCOS.

Type 1 diabetes & cardiovascular disease.

Individuals with type 1 diabetes mellitus (T1DM) have a high risk of developing cardiovascular disease (CVD), but some risk factors can be mediated by lifestyle modification and medication. NPs should understand evidence-based management approaches to counsel patients with T1DM on appropriate self-management interventions to reduce the likelihood of CVD.