Virginia G. Dunbar

Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting

Purpose The purpose of this study was to determine whether “clinical inertia”—inadequate intensification of therapy by the provider—could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. Methods In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. Results Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). Conclusions Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.

Exercise preferences and barriers in urban African Americans with type 2 diabetes.

PURPOSE The purpose of this study was to determine physical activity preferences and barriers to exercise in an urban diabetes clinic population. METHODS A survey was conducted of all patients attending the clinic for the first time. Evaluation measures were type and frequency of favorite leisure-time physical activity, prevalence and types of reported barriers to exercise, and analysis of patient characteristics associated with reporting an obstacle to exercise. RESULTS For 605 patients (44% male, 89% African American, mean age = 50 years, mean duration of diabetes = 5.6 years), the average frequency of leisure activity was 3.5 days per week (mean time = 45 minutes per session). Walking outdoors was preferred, but 52% reported an exercise barrier (predominantly pain). Patients who cited an impediment to physical activity exercised fewer days per week and less time each session compared with persons without a barrier. Increasing age, body mass index, college education, and being a smoker increased the odds of reporting a barrier; being male decreased the chances. Men reported more leisure-time physical activity than women. Exercise preferences and types of barriers changed with age. CONCLUSIONS Recognition of patient exercise preferences and barriers should help in developing exercise strategies for improving glycemic control.

Barriers to Diabetes Education in Urban Patients Perceptions, Patterns, and Associated Factors

Purpose This study explored patients’ perceptions of barriers to diabetes education among a mostly African American population of adults with diabetes. Methods A survey was conducted among 605 new patients attending an urban outpatient diabetes clinic. The questionnaire gathered information on issues patients believed would adversely affect their ability to learn about diabetes. The type and frequency of education barriers were evaluated, and variables associated with reporting an obstacle were analyzed. Results Average patient age was 50 years, diabetes duration was 5.6 years, body mass index was 32 kg/m2, and hemoglobin A1C was 9.1%. The majority (56%) were women, 89% were African American, and 95% had type 2 diabetes. Most respondents (96%) had received some prior instruction in diabetes care; however, 53% anticipated future difficulties learning about diabetes. The most commonly cited concerns were poor vision (74%) and reading problems (29%). Patients with a perceived barrier to diabetes education were older (P < .001) than were persons without a barrier, and they differed in both employment and educational status (both P < .001). In adjusted analyses, older age, male gender, being disabled, and having an elementary education or less were associated with a significantly increased likelihood of having a barrier to diabetes education, whereas having a college education decreased the odds. Higher hemoglobin A1C levels also tended to be associated with a greater chance of reporting an education barrier (P = .05). Conclusions A substantial number of persons anticipated a barrier to diabetes education. Interventions at multiple levels that address the demographic and socioeconomic obstacles to diabetes education are needed to ensure successful self-management training.

A Comparison of the Karyotypes of Six Species of the Genus Macaca and a Species of the Genus Cercocebus

Karyotypes from 72-hour whole blood cultures were compared for six species of macaques (Macaca arctoides, M. fascicularis, M. mulatta, M. nemestrina, M. nigra, and M. radiata) and one species of mangabey (Cercocebus atys). G-bands, sequential C-bands, and late replication patterns were studied. Results showed a variation in a single chromosome pair which differentiated C. atys from the macaques. Heteromorphic variation in silver stained nucleolar organizing regions was seen between and within individuals. This data supports previous work showing the highly conserved nature of the chromosomes of the subfamily Cercopithecus.

High Prevalence of Albuminuria Among African-Americans With Short Duration of Diabetes

These two conditions are considered variants of the same defect of the stimulatory guanine nucleotide-binding (Gs) protein of adenylate cyclase, which is necessary for parathyroid hormone and other hormones such as gonadotropin, beta-adrenergic agonist, and thyrotropin to use cAMP as an intracellular second messenger. We described two related women with apparent AHO and late-onset diabetes. Both patients had normal serum calcium levels, normal parathyroid hormone levels, and the characteristic somatic features of short stature, round face, obesity, and shortened fourth and fifth metacarpals and metatarsals, consistent with pseudo-PHP Both disorders, PHP and pseudo-PHP, can occur within the same family, and there is accumulating evidence that genomic imprinting is involved in the disease (1). Full phenotypic expression (AHO and parathyroid hormone resistance, as in PHP type la) occurs in maternally transmitted cases, whereas partial expression (AHO without parathyroid hormone resistance, as in pseudo-PHP) occurs when the gene is paternally transmitted. The pedigree of our patients showed genetic transmission from their father. Patients with type 2 diabetes have defects in insulin action, abnormal insulin secretion, and increased hepatic glucose production. Although precise pathways responsible for these defects have not been thoroughly identified, they are likely to be genetically heterogenous with mutations in several different genes that are able to cause hyperglycemia. Some reported genetic loci for type 2 diabetes have been mapped on chromosome 20q, chromosome 7p, chromosome 12q, chromosome 2, and so forth (2,3). In most cases of AHO, reduced levels of Gs protein a subunit (Gsa protein) have been found. A number of deactivating mutations in the gene for Gsa protein located on chromosome 20ql3 have been described for this disorder (1), but del(2)(q37) has also been described in some AHO patients (4) and thus explains the heterogeneity observed in this AHO disorder. PHP type la or pseudo-PHP is assumed to be a Gsa protein problem and this protein is encoded by chromosome 20ql3. 2-3. Occasionally, these disorders may be associated with resistance of diverse target tissues to hormones and neurotransmitters whose actions require stimulation of adenylate cyclase and thus open calcium channels. It should be considered whether this Gsa protein problem will lead to diabetes with insulin resistance. Certainly, either these pseudo-PHP women with type 2 diabetes have a mutation in the Gsa protein or nearby genome for its susceptibility to type 2 diabetes, or they represent just a phenomenon of coincidence. Further evaluation and collection of cases are necessary to define the possible role and interrelationship of pseudo-PHP and type 2 diabetes.