Sheila H. Roman

Effect of a Bicultural Community Health Worker on Completion of Diabetes Education in a Hispanic Population

OBJECTIVE To determine the effect of a bicultural community health worker (CHW) on completion of diabetes education in an inner-city Hispanic patient population and to evaluate the impact of completion of the education program on patient knowledge, self-care behaviors, and glycemic control. RESEARCH DESIGN AND METHODS Patients were randomized into CHW intervention and non-CHW intervention groups. All patients received individualized, comprehensive diabetes education from a certified diabetes nurse educator after baseline demographic information, diabetes knowledge, diabetes self-care practices, and glycohemoglobin levels were assessed. Rates of education program completion were determined. Diabetes knowledge, self-care practices, and glycohemoglobin levels were reassessed at program completion and at a later postprogram follow-up medical appointment and compared to baseline. Logistic regression analysis and the Mantel-Haenszel χ2 statistic were used to determine the effect of the CHW assignment on program completion. Analyses of covariance were performed with end-of-treatment behavior scores, knowledge scores, and glycohemoglobin levels as outcome variables, controlling for baseline values and testing for the effect of CHW assignment. RESULTS Of 64 patients enrolled in the study, 40 (63%) completed and 24 (37%) dropped out before completing the diabetes education program. Of the patients having CHW intervention, 80% completed the education program, compared with 47% of patients without CHW intervention (P = 0.01). “Dropouts” were younger (age 47.5 ± 12.5 years [mean ± SD]) compared with patients who completed the program (55.9 ± 9.9 years) (P = 0.004). Dropout status showed no significant relationship to educational level achieved or literacy level. For the program “completers,” knowledge levels and selected self-care practices significantly improved, and glycohemoglobin levels improved from a baseline level of 11.7% to 9.9% at program completion (P = 0.004) and 9.5% at the postprogram follow-up (P < 0.001). The effect of the CHW assignment on program completion, controlling for financial status and language spoken, was extremely robust (P = 0.007). The effect of the CHW on knowledge, self-care behavior, or glycohemoglobin outcome variables was not statistically significant. CONCLUSIONS These findings suggest that intervention with a bicultural CHW improved rates of completion of a diabetes education program in an inner-city Hispanic patient population irrespective of literacy or educational levels attained. Our data further suggests that completion of individualized diabetes educational strategies leads to improved patient knowledge, self-care behaviors, and glycemic control.

Higher incidence of diabetes in liver transplant recipients with hepatitis C.

We assessed the clinical and biochemical parameters associated with the development of posttransplantation diabetes (PTDM) in 52 liver transplant recipients followed up for 1 year. Diabetes was present before transplantation in 9.6% (5 of 52) of patients, and PTDM occurred in 23% (11 of 47) of the remaining liver transplant recipients. Of the 13 patients who had hepatitis C as the cause of their liver failure (HC-LD), 8 (62%) developed PTDM; of the 34 patients with other causes of liver failure, 3 (9%) developed PTDM (p < 0.001). Posttransplantation diabetes was also associated with the development of early posttransplantation hyperglycemia, a higher number of liver rejection episodes, and lower serum albumin levels at 6 months. The association of PTDM with HC-LD remained significant in a logistic regression model after adjustment for potential confounding variables. We conclude that PTDM is common in liver transplant recipients. Associated clinical parameters predictive of PTDM include a diagnosis of HC-LD before transplantation, the development of early hyperglycemia after transplantation, multiple episodes of posttransplantation liver rejection and low serum albumin levels at 6 months. The fact that HC-LD remained an independent risk factor for the development of PTDM may suggest a direct or immune-mediated pancreatic effect of the virus.

MANAGEMENT OF DIABETES MELLITUS FROM A PUBLIC HEALTH PERSPECTIVE

This article details the scope and the impact of diabetes in the United States including the prevalence, demographics, morbidity and mortality, and costs. The current status of medical care for diabetes is used to illustrate why diabetes should be approached from a proactive public health perspective, rather than a reactive, traditional medical perspective. The importance of early diagnosis and secondary intervention programs for prevention and early detection of diabetes complications are emphasized. The specialty-based intensive management model, the primary care-based co-management model, the systems management model, and the mini-clinic models are presented as potential paradigms for approaching diabetes care from a public health perspective. Requirements for implementing a public health approach to diabetes care including long-term planning, targeting patients for improved care, and goal setting for outcomes of care, are discussed.

Leukocyte Scanning With 111In Is Superior to Magnetic Resonance Imaging in Diagnosis of Clinically Unsuspected Osteomyelitis in Diabetic Foot Ulcers

OBJECTIVE To compare the accuracies of MRI and leukocyte scanning in diagnosing clinically unsuspected osteomyelitis in diabetic foot ulcers. RESEARCH DESIGN AND METHODS A prospective study of 16 diabetic foot ulcers in 12 patients, including both ambulatory and hospitalized patients, was performed at a university medical center. Pedal images were obtained by leukocyte scanning with [111In]oxyquinoline and MRI. Definitive diagnosis of osteomyelitis then was determined by bone biopsy for culture and histology. RESULTS Biopsy-proven osteomyelitis was present in 7 (44%) of the 16 foot ulcers. The diagnosis was suspected clinically in 0%. Leukocyte scanning was 100% sensitive, whereas MRI was only 29% sensitive in diagnosing osteomyelitis in diabetic foot ulcers. Specificities were 67 and 78%, respectively. The positive and negative predictive values (70 and 100%, respectively) for the leukocyte scan also were > those of MRI (50 and 58%, respectively). CONCLUSIONS Leukocyte scanning is superior to MRI in detecting clinically unsuspected osteomyelitis in diabetic foot ulcers.

Maternal characteristics, neonatal outcome, and the time of diagnosis of gestational diabetes

OBJECTIVE A study was undertaken to evaluate the yield of early, routine screening for gestational diabetes and to determine whether maternal characteristics and neonatal outcome differ according to the time of diagnosis. STUDY DESIGN A total of 2776 women were screened before 24 weeks of gestation, and each was delivered of a singleton infant on the clinic service of Mount Sinai Hospital in New York City between January 1986 and January 1991. RESULTS An abnormal glucose tolerance test was diagnosed in 102 women < 24 weeks and in 252 patients at > or = 24 weeks of gestation. Logistic regression analysis showed that the group diagnosed early was significantly older and more likely to have hypertensive disorders and low maternal weight gain and to require insulin treatment, compared with the group diagnosed late. No significant differences were evident in neonatal outcome. CONCLUSIONS These data indicate that a sizable proportion of patients with gestational diabetes can be diagnosed early in pregnancy. The differences in maternal characteristics and insulin requirements between the early- and late-diagnosis groups also suggest heterogeneity of gestational diabetes or the possibility of preexisting impaired glucose intolerance in the early-diagnosis group.

Autoimmune thyroid disease and thyroid cell class II major histocompatibility complex antigens.

Differences in the immune response to antigenic stimuli, including thyroid autoantigens, have been linked to a group of genes known collectively as the Major Histocompatibility Complex (MHC), which in humans is referred to as the Human Leukocyte Antigen (HLA) complex (Benacerraf, 1981). These genes encode a series of polymorphic cell surface molecules; the class I, 11 & I11 antigens. Classically, class I antigens are expressed on all nucleated cells in the body and are recognized by cytotoxic and suppressor T cells. Class I1 antigens, however, are primarily restricted in their constitutive expression to cells of the immune system and are recognized by the T helper cell subset. Class I11 antigens represent components of the complement pathway. Theories on the aetiology of autoimmune thyroid disease have often invoked a ‘thyroid component’ to such immune responses, but the evidence has been indirect and usually in the form of inherited metabolic abnormalities present in the thyroid cell rather than an immunologically-defined antigen (Wick et al., 1982). However, recent studies on intrathyroidal lymphocyte function have demonstrated the potent role of thyroid antigenic stimulation within the target organ (Totterman et al., 1979; McLachlan et al., 1983; Londei et al., 1984). The finding of MHC class I1 antigens on the surface of the murine thyroid cell (Salamero et al., 1981), and later in human thyroid epithelium (Hanafusa et al., 1983), has focused attention on the generalized facilitation by MHC class I1 antigens in the development of thyroid autoimmunity. This review includes a basic introduction to the class I1 antigens and discusses our present understanding of their involvement in the development of human thyroid autoimmunity.

HLA class II antigen expression and the autoimmune thyroid response in patients with benign and malignant thyroid tumors

To further understand the relationship between the immune system and the neoplastic human thyroid cell we investigated the degree of intrathyroidal lymphocytic infiltration and thyroid HLA class II expression in 17 patients with thyroid tumors. In another 60 thyroid tumor patients the association of thyroidal lymphocytic infiltration with thyroid autoantibody production was analyzed. In total 117 thyroid tissues were examined including tissue obtained at autopsy (n = 28), fetal thyroid tissue (n = 4), thyroid samples obtained from areas distant from benign follicular adenomas (n = 5), and 80 abnormal thyroids including patients with benign (n = 53) or malignant (n = 24) thyroid tumors and Hashimotos thyroiditis (n = 3). Normal adult and fetal thyroid tissue had no significant lymphocytic infiltration and no detectable HLA-DR, -DP, or -DQ antigens on their thyroid follicular epithelial cells. The degree of lymphocytic infiltration in the nonneoplastic thyroid tissue of thyroid glands with benign and malignant thyroid tumors varied considerably and correlated with the presence and titer of serum thyroid autoantibodies measured by sensitive ELISA techniques. However, all but one of the benign follicular adenomas had thyroid cells negative for HLA class II determinants despite the presence of infiltrating lymphocytes, while 7 of 10 thyroid carcinomas expressed class II antigen (principally HLA-DR) even when only minor degrees of lymphocytic infiltration were present. These data indicate a correlation between lymphocytic infiltrates and serum thyroid autoantibody titers but the relationship with HLA class II expression is more complex. Since we have previously shown that HLA class II antigen expression can be induced by local interferon-gamma secretion, presumably from activated T cells, we conclude that estimates of simple thyroid lymphocytic infiltration and serum autoantibody secretion do not correlate with the degree of intrathyroidal T-cell activation. Furthermore, our observation of increased expression of HLA class II antigens in thyroid cancer suggests considerable cellular heterogeneity in susceptibility to HLA class II antigen induction in human thyroid disease.

Thyroid autoantibodies in HLA-genotyped type 1 diabetic families: sex-limited DR5 association with thyroid microsomal antibody.

Thyroid autoantibodies are common in Type I diabetics and their first degree relatives and may be part of the autoimmune diathesis present within such families. We have measured the prevalence of microsomal (M‐Ab) and thyroglobulin (Tg‐Ab) autoantibodies in 84 HLA‐typed families having a Type 1 diabetic child, using enzyme‐linked immunosorbent assay techniques. Thyroid autoantibodies were detectable in 201/407 (49%) individuals in these families. Both autoantibodies were significantly more frequent in the subsets of parents, diabetic children and their non‐diabetic siblings than in groups of control adults and children. The prevalence of these autoantibodies in the diabetic families was increased in both sexes with a female:male ratio of 1.4:1. Antigen DR5 was significantly associated with M‐Ab production but only for male subjects (P= 0.005 after correction for the number of DR antigens tested). No significant associations were encountered for Tg‐Ab. Within‐family analyses indicated that thyroid autoantibodies occurred with increased prevalence in HLA‐identical or haplo‐identical siblings of autoantibody‐positive index cases in comparison to control children. We conclude (1) the DR association with thyroid autoantibody production in this diabetes‐selected population was thyroiditis‐related and not diabetes‐related, and (2) the DR5 association was restricted to males and the production of M‐Ab. These data are consistent with the hypothesis that multiple genetic and non‐genetic factors played a role in the high prevalence of thyroid autoantibodies in this population.

Influence of an interdisciplinary diabetes specialist team on short-term outcomes of diabetes at a community health center.

OBJECTIVE To assess the effect on short-term diabetes outcomes of intervention with an interdisciplinary diabetes specialist team at a primary-care community health center in East Harlem, New York City. METHODS An interdisciplinary diabetes specialist team, consisting of a diabetologist, a bicultural certified diabetes nurse-educator, and a nutritionist, attended weekly clinics at a primary-care community health center in East Harlem. Emphasis was placed on communicating in the patients primary language and providing nutritional counseling, diabetes education, and diabetes management. After 1 year, a retrospective review of medical records for patients seen by the diabetes team was performed to assess the influence of this intervention on performance of home glucose monitoring (HGM), frequency of hypoglycemia, and changes in diabetes treatment regimens. Of 70 patients referred to the diabetes team by their primary-care providers, 50 underwent follow-up for at least 6 months and were included in the statistical analysis. RESULTS Of the 50 study patients, 94% had type 2 diabetes, with a mean duration of 11.2 years. Eighty-two percent were Hispanic, and 18% were Afro-American. The mean age was 54.6 years. Microvascular complications were present in 44%, and macrovascular complications were present in 22%. HGM was done by 13 patients (26%) before and 33 patients (66%) after diabetes team intervention (P<0.001). Before intervention by the diabetes team, 14 patients (28%) were having episodes of unrecognized hypoglycemia. Unrecognized hypoglycemia resolved after intervention in all but two patients with type 1 diabetes (P<0.001). Before intervention, diabetes treatment was dietary in 6 patients, a sulfonylurea in 19, and insulin in 25; after intervention, 5 patients had dietary management of their diabetes, 14 were taking a sulfonylurea, and 31 were receiving insulin (P<0.05). CONCLUSION Providing access to an interdisciplinary diabetes specialist team at the site of primary care had a beneficial effect on short-term diabetes outcomes in inner-city Hispanic and Afro-American patients with diabetes. Providing specialty care in the primary-care setting may be one model for improving the quality and long-term outcomes of diabetes care, particularly in high-risk populations.

Role of MHC class II antigen expression in thyroid autoimmunity

Major histocompatibility complex (MHC) class I1 antigens are represented in man by the HLA-D region gene family which is composed of polymorphic genetic loci (DR, DP, and DQ) mapping to the short arm of chromosome 6, in mice by the Ia gene family on chromosome 17 (IA and IE), and in the rat by RTI.B, D, and H gene regions (FIG. l).’ The typical M H C class I1 antigen molecule is a heterodimer, consisting of an alpha (34-kd) and a beta (28-kd) glycopeptide chain that is linked noncovalently within the plasma membrane and is associated intracellularly with an invariant (33-kd) glycopeptide.* The genetic variation both within the human population and within different animal species a t the MHC class I1 region is largely attributable to the amino acid sequence differences within the first external domain of the polymorphic beta chain. Many studies have demonstrated the association between M H C genes, particularly those of class 11, and autoimmune thyroid disease in animals and humans’ (TABLE 1). The relative risk of autoimmune thyroid disease attached to any of these antigens (principally HLA-DR3 and DR5) in humans is low, and 30-50% of patients with disease do not express an associated HLA antigen. However, studies of HLA haplotypes within individual multiplex families of patients with autoimmune thyroid disease indicate that unique familial associations may be of primary importance: a fact that improved methods of HLA typing may detect in the general population. Similarly, particular murine and rat strains are known to be high or low immunoresponders to thyroid antigens, and this responsiveness has been linked to the M H C class I1 gene ~ o m p l e x . ~ * ~ In addition to these disease-specific relationships, particular HLA haplotypes have been associated with abnormal immune responsiveness of a nonantigen-specific nature. For example, normal HLA-DR3 individuals have less effective T-cell suppressor function than do non-DR3 normal^.^