Sofija E. Zagarins

Nurse diabetes case management interventions and blood glucose control: results of a meta-analysis.

We conducted a meta-analysis of studies reporting diabetes case management interventions to examine the impact of case management on blood glucose control (HbA1c). Databases used for the search included Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo. A composite estimate of effect size was calculated using a random effects model and subgroup analyses were conducted. Twenty-nine salient studies involving 9397 patients had sufficient data for analysis. Mean patient age was 63.2 years, 49% were male, and ethnicity/race was 54% White. Type 2 diabetes was the focus in 91% of studies. Results showed a large overall effect size favoring case management intervention over controls or baseline values on HbA1c (ES=0.86, 95%CI: 0.52-1.19, Z=5.0, p<0.001). This corresponds to a mean HbA1c reduction of 0.89 (95%CI: 0.63-1.15). Subgroup analyses showed clinical setting, team composition, and baseline HbA1c were important predictors of effect size, but not diabetes self-management education which was poorly described or absent in most diabetes case management interventions examined. Nurse-led case management provides an effective clinical strategy for poorly controlled diabetes based on a meta-analysis of clinical trials focusing on blood glucose control.

Motivational interviewing delivered by diabetes educators: Does it improve blood glucose control among poorly controlled type 2 diabetes patients? ☆ ☆☆

AIM To determine whether glycemic control is improved when motivational interviewing (MI), a patient-centered behavior change strategy, is used with diabetes self management education (DSME) as compared to DSME alone. METHODS poorly controlled type 2 diabetes (T2DM) patients (n=234) were randomized into 4 groups: MI+DSME or DSME alone, with or without use of a computerized summary of patient self management barriers. We compared HbA1c changes between groups at 6 months and investigated mediators of HbA1c change. RESULTS study patients attended the majority of the four intervention visits (mean 3.4), but drop-out rate was high at follow-up research visits (35%). Multiple regression showed that groups receiving MI had a mean change in HbA1c that was significantly lower (less improved) than those not receiving MI (t=2.10; p=0.037). Mediators of HbA1c change for the total group were diabetes self-care behaviors and diabetes distress; no between-group differences were found. CONCLUSIONS DSME improved blood glucose control, underlining its benefit for T2DM management. However, MI+DSME was less effective than DSME alone. Overall, weak support was found for the clinical utility of MI in the management of T2DM delivered by diabetes educators.

Evaluation of Clinical Outcomes for Gastric Bypass Surgery: Results from a Comprehensive Follow-up Study

BackgroundLaparoscopic gastric bypass (LGB) surgery markedly increases percent excess weight loss (%EWL) and obesity-related co-morbidities. However, poor study quality and minimal exploration of clinical, behavioral, and psychosocial mechanisms of weight loss have characterized research to date.MethodsWe conducted a comprehensive assessment of n=100 LGB patients surveyed 2–3 years following surgery using standardized measures.ResultsMean %EWL at follow-up was 59.1±17.2%. This high level of weight loss was associated with a low rate of metabolic syndrome (10.6%), although medications were commonly used to achieve control. Mean adherence to daily vitamin and mineral supplements important to the management of LGB was only 57.6%, and suboptimal blood chemistry levels were found for ferritin (32% of patients), hematocrit (27%), thiamine (25%), and vitamin D (19%). Aerobic exercise level (R2=0.08) and pre-surgical weight (R2=0.04) were significantly associated with %EWL, but recommended eating style, fluid intake, clinic follow-up, and support group attendance were not. Psychosocial adjustment results showed an absence of symptomatic depression (0%), common use of antidepressant medications (32.0%), low emotional distress related to the post-surgical lifestyle (19.8±14.0; scale range 0–100), a high level of perceived benefit from weight loss in terms of functioning and emotional well-being (82.7±17.9; scale range 0–100), and a change in marital status for 26% of patients.ConclusionsAt 2–3 years following LGB surgery aerobic exercise, but not diet, fluid intake, or attendance at clinic visits or support groups, is associated with %EWL. Depression is symptomatically controlled by medications, lifestyle related distress is low, and marital status is significantly impacted.

Association of inflammation markers with menstrual symptom severity and premenstrual syndrome in young women

STUDY QUESTION Are markers of chronic inflammation associated with menstrual symptom severity and premenstrual syndrome (PMS)? SUMMARY ANSWER Serum levels of inflammatory markers, including interleukin (IL)-2, IL-4, IL-10, IL-12 and interferon (IFN)-γ were positively associated with menstrual symptom severity and/or PMS in young women. WHAT IS KNOWN ALREADY Chronic inflammation has been implicated in the etiology of depression and other disorders that share common features with PMS, but whether inflammation contributes to menstrual symptom severity and PMS is unknown. STUDY DESIGN, SIZE, DURATION Cross-sectional study of 277 women aged 18-30 years, conducted in 2006-2011. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants provided information on menstrual symptoms, lifestyle, diet, anthropometry and other factors by questionnaire and/or direct measurement, and a mid-luteal phase fasting blood sample was taken between 7 a.m. and 12 p.m. Total, physical and affective menstrual symptom scores were calculated for all participants, of whom 13% (n = 37) met criteria for moderate-to-severe PMS and 24% (n = 67) met PMS control criteria. Inflammatory factors assayed in serum included IL-1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12p70, IL-13, tumor necrosis factor-α, granulocyte macrophage colony stimulating factor, IFN-γ and C-reactive protein. MAIN RESULTS AND THE ROLE OF CHANCE After adjustment for age, smoking status and BMI, total menstrual symptom score was positively associated with levels of IL-2 (percentage difference in women at the 75th percentile of total symptom score versus at the 25th percentile = 24.7%; P = 0.04), IL-4 (21.5%; P = 0.04), IL-10 (28.0%; P < 0.01) and IL-12 (42.0%; P = 0.02) in analyses including all participants. Affective menstrual symptom score was linearly related to levels of IL-2 (percentage difference at 75th percentile versus 25th percentile = 31.0%; P = 0.02), while physical/behavioral symptom score was linearly related to levels of IL-4 (19.1%; P = 0.03) and IL-12 (33.2%; P = 0.03). Additionally, mean levels of several factors were significantly higher in women meeting PMS criteria compared with women meeting control criteria, including IL-4 (92% higher in cases versus controls; P = 0.01); IL-10 (87%; P = 0.03); IL-12 (170%; P = 0.04) and IFN-γ (158%; P = 0.01). LIMITATIONS, REASONS FOR CAUTION Our study has several limitations. While a single blood sample may not perfectly capture long-term levels of inflammation, ample data suggest that levels of cytokines are stable over time. Although we did not base our assessment of PMS on prospective symptom diaries, we used validated criteria to define PMS cases and controls, and excluded women with evidence of comorbid mood disorders. Furthermore, because of the cross-sectional design of the study, the temporal relation of inflammatory factors and menstrual symptoms is unclear. WIDER IMPLICATIONS OF THE FINDINGS To our knowledge, this is among the first studies to suggest that inflammatory factors may be elevated in women experiencing menstrual symptoms and PMS. Additional studies are needed to determine whether inflammation plays an etiologic role in PMS. STUDY FUNDING/COMPETING INTERESTS This study was funded by the Departments of Public Health and Nutrition and by a Faculty Research Grant, University of Massachusetts Amherst. No conflicts declared. TRIAL REGISTRATION NUMBER N/A.

Dietary vitamin D intake, 25-hydroxyvitamin D3 levels and premenstrual syndrome in a college-aged population

High dietary intake of vitamin D may reduce the risk of premenstrual syndrome (PMS), perhaps by affecting calcium levels, cyclic sex steroid hormone fluctuations, and/or neurotransmitter function. Only a small number of previous studies have evaluated this relationship and none have focused on young women. We assessed this relationship in a cross-sectional analysis within the UMass Vitamin D Status Study. Between 2006 and 2008, 186 women aged 18-30 (mean age=21.6 years) completed a validated food frequency questionnaire, additional questionnaires to assess menstrual symptoms and other health and lifestyle factors, and provided a fasting blood sample collected during the late luteal phase of their menstrual cycle. Among all study participants, results suggested the possibility of an inverse association between intake of vitamin D from food sources and overall menstrual symptom severity, though were not statistically significant; mean intakes in women reporting menstrual symptom severity of none/minimal, mild, and moderate/severe were 253, 214, and 194 IU/day, respectively (P=0.18). From among all study participants, 44 women meeting standard criteria for PMS and 46 women meeting control criteria were included in additional case-control analyses. In these women, after adjustment for age, body mass index, smoking status and total calcium intake, higher intake of vitamin D from foods was associated with a significant lower prevalence of PMS. Women reporting vitamin D intake from food sources of >or=100 IU/day had a prevalence odds ratio of 0.31 compared to those reporting<100 IU/day (95% confidence interval=0.10-0.98). Late luteal phase 25-hydroxyvitamin D3 levels were not associated with prevalent PMS. Results from this pilot study suggest that a relationship between vitamin D and PMS is possible, though larger studies are needed to further evaluate this relationship and to investigate whether 25-hydroxyvitamin D3 levels in the follicular or early luteal phases of the menstrual cycle may be related to PMS risk.

Comprehensive Diabetes Management Program for Poorly Controlled Hispanic Type 2 Patients at a Community Health Center

Technology and improved care coordination models can help diabetes educators and providers meet national care standards and provide culturally sensitive diabetes education that may improve diabetes outcomes. The purpose of the study was to evaluate the clinical usefulness of a nurse-led diabetes care program (Comprehensive Diabetes Management Program, CDMP) for poorly controlled Hispanic type 2 diabetes (T2DM) patients in an urban community health center setting. Patients were randomized to the intervention condition (IC; n = 21) or an attention control condition (AC; n = 18). IC and AC conditions were compared on rates of adherence to national clinical practice guidelines (blood glucose, blood pressure, foot exam, eye exam), and levels of diabetes distress, depression, and treatment satisfaction. IC patients had a significant improvement in A1C from baseline to 12-month follow-up compared with AC (−1.6% ± 1.4% versus −0.6% ± 1.1%; P = .01). The proportion of IC patients meeting clinical goals at follow-up tended to be higher than AC for A1c (IC = 45%; AC = 28%), systolic blood pressure (IC = 55%; AC = 28%), eye screening (IC = 91%; AC = 78%), and foot screening, (IC = 86%; AC = 72%). Diabetes distress and treatment satisfaction also showed greater improvement for IC than AC (P = .05 and P = .06, respectively), with no differences for depression. The CDMP intervention was more effective than an attention control condition in helping patients meet evidence-based guidelines for diabetes care.

Household Chemical Exposures and the Risk of Canine Malignant Lymphoma, a Model for Human Non-Hodgkin’s Lymphoma

BACKGROUND Epidemiologic studies of companion animals offer an important opportunity to identify risk factors for cancers in animals and humans. Canine malignant lymphoma (CML) has been established as a model for non-Hodgkins lymphoma (NHL). Previous studies have suggested that exposure to environmental chemicals may relate to development of CML. METHODS We assessed the relation of exposure to flea and tick control products and lawn-care products and risk of CML in a case-control study of dogs presented to a tertiary-care veterinary hospital (2000-2006). Cases were 263 dogs with biopsy-confirmed CML. Controls included 240 dogs with benign tumors and 230 dogs undergoing surgeries unrelated to cancer. Dog owners completed a 10-page questionnaire measuring demographic, environmental, and medical factors. RESULTS After adjustment for age, weight, and other factors, use of specific lawn care products was associated with greater risk of CML. Specifically, the use of professionally applied pesticides was associated with a significant 70% higher risk of CML (odds ratio(OR)=1.7; 95% confidence interval (CI)=1.1-2.7). Risk was also higher in those reporting use of self-applied insect growth regulators (OR=2.7; 95% CI=1.1-6.8). The use of flea and tick control products was unrelated to risk of CML. CONCLUSIONS Results suggest that use of some lawn care chemicals may increase the risk of CML. Additional analyses are needed to evaluate whether specific chemicals in these products may be related to risk of CML, and perhaps to human NHL as well.

Are existing measures of overall diet quality associated with peak bone mass in young premenopausal women

BACKGROUND   Low peak bone mass in young adulthood is associated with an increased risk of osteoporosis and fracture after menopause, and an understanding of the modifiable factors that contribute to low peak bone mass is important for fracture prevention. Diet is an important modifiable factor linked to bone health and, although studies have examined the role of individual dietary components in bone health, bone growth and maintenance are complex processes, and such studies may not adequately represent the role of diet in these processes. METHODS   To address this issue, a cross-sectional analysis of 226 healthy, premenopausal women aged 18-30 years was conducted to determine whether existing indices of overall diet quality are associated with bone density in premenopausal women nearing peak bone mass. Bone density was measured using dual-energy X-ray absorptiometry and diet quality was measured using two overall diet scores based on current dietary guidelines: the Recommended Food Score and the Alternate Healthy Eating Index (AHEI). RESULTS   In the multiple linear regression, bone density did not increase across quartiles of either diet quality score and was not associated with continuous diet quality variables. Furthermore, none of the individual AHEI components (e.g. fruit intake, vegetable intake) were associated with bone density. CONCLUSIONS   These findings suggest that existing diet quality scores are not appropriate for studies of peak bone mass, most likely because they do not give sufficient weight to foods and nutrients important to bone health. We recommend the development of a diet pattern index that better predicts bone mass measures.

An Internet-Based Diabetes Management Platform Improves Team Care and Outcomes in an Urban Latino Population

OBJECTIVE To compare usual diabetes care (UDC) to a comprehensive diabetes care intervention condition (IC) involving an Internet-based “diabetes dashboard” management tool used by clinicians. RESEARCH DESIGN AND METHODS We used a parallel-group randomized design. Diabetes nurses, diabetes dietitians, and providers used the diabetes dashboard as a clinical decision support system to deliver a five-visit, 6-month intervention to 199 poorly controlled (HbA1c >7.5% [58 mmol/mol]) Latino type 2 diabetic (T2D) patients (mean age 55 years, 60% female) at urban community health centers. We compared this intervention to an established, in-house UDC program (n = 200) for its impact on blood glucose control and psychosocial outcomes. RESULTS Recruitment and retention rates were 79.0 and 88.5%, respectively. Compared with UDC, more IC patients reached HbA1c targets of <7% (53 mmol/mol; 15.8 vs. 7.0%, respectively, P < 0.01) and <8% (64 mmol/mol; 45.2 vs. 25.3%, respectively, P < 0.001). In multiple linear regression adjusting for baseline HbA1c, adjusted mean ± SE HbA1c at follow-up was significantly lower in the IC compared with the UDC group (P < 0.001; IC 8.4 ± 0.10%; UDC 9.2 ± 0.10%). The results showed lower diabetes distress at follow-up for IC patients (40.4 ± 2.1) as compared with UDC patients (48.3 ± 2.0) (P < 0.01), and also lower social distress (32.2 ± 1.3 vs. 27.2 ± 1.4, P < 0.01). There was a similar, statistically significant (P < 0.01) improvement for both groups in the proportion of patients moving from depressed status at baseline to nondepressed at follow-up (41.8 vs. 40%; no significance between groups). CONCLUSIONS The diabetes dashboard intervention significantly improved diabetes-related outcomes among Latinos with poorly controlled T2D compared with a similar diabetes team condition without access to the diabetes dashboard.

The Association of Lean Mass and Fat Mass With Peak Bone Mass in Young Premenopausal Women

Total body mass is a major determinant of bone mass, but studies of the relative contributions of lean mass (LM) and fat mass (FM) to bone mass have yielded conflicting results. This is likely because of the use of bone measures that are not adequately adjusted for body size and, therefore, not appropriate for analyses related to body composition, which is also correlated with body size. We examined the relationship between body composition and peak bone mass in premenopausal women aged 18-30 yr using both size-dependent and size-adjusted measures of bone density and body composition, as well as statistical models adjusted for size-related factors. We measured total bone mass and areal bone density using dual-energy X-ray absorptiometry, and used established formulas to calculate estimates of volumetric (size-adjusted) bone density. LM tended to be positively associated with bone both before and after adjustment for size-related factors. FM and body fat percentage, however, were positively associated with size-dependent bone measures, but adjusting for size removed or reversed this association. These findings suggest that the association between bone mass and body composition, especially FM, is dependent on the bone measures analyzed, and that determining the most appropriate size-adjustment techniques is critical for understanding this relationship.