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Collaborative Islet Transplant Registry Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2005. (CD-ROM)

The number of transplant centers performing clinical islet cell transplantation continues to increase, as does the number of centers participating in and reporting to the Collaborative Islet Transplant Registry (CITR). The CITR was founded in September 2001 to provide support for logistics, data capture, quality control monitoring, statistical design and analysis, and other Registry activities. This CD-ROM provides the second Annual Report of the CITR, supporting the mission of supporting progress and promoting safety in islet or beta cell transplantation. The disk contains the Annual Report in PDF format, March 2005 Case Report Forms in PDF format, and the figures and tables from the Annual Report in 210 PowerPoint slides. The information is drawn from 19 North American islet transplant programs, representing 138 transplant recipients. The Report describes patient care, surgical experiences, follow-up care, complications, hypoglycemia, insulin independence, and immunosuppression in these patients. The Report provides data on the recipients, pancreas donors, pancreas preservation, islet processing, islet infusions, recipient treatment, post-transplant islet function, and adverse events. The Report is designed to provide information that can form the basis necessary for the development of islet transplantation as a curative therapy for type 1 diabetes. Readers are referred to the Registry’s website, www.citregistry.org, for more information. 210 figures.

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Current and Future Approaches to Monitoring Glycemia. Advanced Studies in Medicine. 5(10): S1117-S1128 p. December 2005.

The goal of blood glucose monitoring in diabetes is to obtain useful information about the patient’s overall glucose status in order to normalize glucose, prevent hypoglycemia, and minimize hyperglycemia through meaningful and timely interventions. This review article outlines current and future approaches to monitoring glycemia. The author stresses that self-monitoring of blood glucose (SMBG) is the foundation of diabetes care. Studies have shown a direct correlation between the use of SMBG and improved glycosylated hemoglobin (HbA1c) levels, a measure of blood glucose levels over time. Recommendations for patients with type 1 diabetes are to use SMBG at least 3 times daily; the optimal frequency for patients with type 2 diabetes is unknown, but the frequency should be sufficient to reach glucose goals. The accuracy of the results is instrument- and user-dependent, thus the clinician should evaluate each patient’s technique frequently, including use of alternate-site testing. The author considers several obstacles to optimal SMBG, including denial, ignored results, clinician passivity, pain, expense, and inconvenience, any of which can severely compromise a treatment plan. The article concludes with a section on the emerging technology of continuous glucose monitoring (CGM), including a review of the currently available CGM meters, in addition to those meters under development and review by the US Food and Drug Administration. The author focuses on the strengths and limitations of HbA1c measurement and the physiology behind its use as a diabetes marker. Four sidebars cover diabetic ketoacidosis; the electrochemistry of second-generation blood glucose meters; the role of the diabetes educator in implementing continuous glucose monitoring; and the history of the use of HbA1c in diabetes management. 7 figures. 4 tables. 25 references.

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Detection, Prevention, and Treatment of Hypoglycemia in the Hospital. Diabetes Spectrum. 18(1): 39-44. Winter 2005.

The threat of hypoglycemia is one barrier to providing optimal glycemic control in the inpatient setting. Nurses, physicians, and other health care workers must be vigilant in detecting, treating, and most of all preventing hypoglycemia (low blood glucose levels) in patients with diabetes who are hospitalized. This article discusses the hospital care of this patient population. The author covers detection of hypoglycemia, including signs and symptoms and risk factors; prevention, including recognition of precipitating factors, scheduled insulin therapy, inpatient use of oral agents, bedside glucose monitoring, the role of medical nutrition therapy (MNT), and applying systems; and treatment strategies. The author concludes that identifying risk factors, implementing protocols, avoiding traditional sliding scale insulin regimens, and changing unsafe prescribing behaviors, are ways to avoid severe hypoglycemic events. Reviewing hypoglycemia signs and symptoms with the entire inpatient team, including patients and their significant others, allows for early detection and treatment. The article includes a patient care algorithm.

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Diabetes Care in an Urban Specialty Clinic. Diabetes Spectrum. 18(3): 174-176. Summer 2005.

Interpersonal health communication can affect individuals? awareness, knowledge, attitudes, self-efficacy, skills, and commitment to behavior change. This article reviews the impact of cultural issues, location of the health care setting, and resources on the provision of diabetes care. The author focuses on diabetes care in an urban specialty clinic and uses case studies to illustrate the concepts being discussed. The first case study features an empowered middle-aged woman with longstanding type 2 diabetes; the second case study reports on recurrent hypoglycemia in an individual with type 1 diabetes and a history of alcohol abuse. The author emphasizes that personalizing and involving people in their own care facilitates sustained behavior change. Health communication cannot compensate for inadequate health care or inadequate access to health care services, nor produce sustained change in complex health behaviors without some type of support network. The author cautions that health care providers working with people who have limited resources and education sometimes make the inaccurate assumption that these individuals cannot adequately understand self-care practice recommendations. 5 references.

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Executive Summary. IN: Collaborative Islet Transplant Registry Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. pp. 1-3.

The number of transplant centers performing clinical islet cell transplantation continues to increase, as does the number of centers participating in and reporting to the Collaborative Islet Transplant Registry (CITR). The CITR was founded in September 2001 to provide support for logistics, data capture, quality control monitoring, statistical design and analysis, and other Registry activities. This introductory chapter from the second Annual Report of the CITR describes the progress in islet or beta cell transplantation. This chapter briefly summarizes the annual information that was drawn from 19 North American islet transplant programs, representing 138 transplant recipients. The information focuses on islet-transplant-alone recipients (n = 118), donor, and outcome information. The summary briefly describes patient care, surgical experiences, follow-up care, complications, hypoglycemia, insulin independence, and immunosuppression in these patients. The median age of islet-transplant-alone recipients was 41.6 years and duration of diabetes was 29 years. More than 66 percent of the recipients were female, and all had type 1 diabetes. The median age of the deceased donor for these recipients was 44 years (range 8 to 65 years); 53 percent of the donors were male, and approximately 66 percent were white. At the time of this report, follow-up evaluations had been completed for 112 out of 118 patients. Of these 112 patients, 55 (49.1 percent) are insulin independent, while 39 (34.8 percent) are insulin dependent. Fifteen patients (13.4 percent) have experienced graft failure, while three participants have an unknown insulin status. There is a striking decrease in the occurrence of severe hypoglycemic events subsequent to the first infusion. The majority of the recipients received daclizumab for induction and sirolimus combined with tacrolimus for maintenance immunosuppression. Information about adverse events, received from 18 of the 19 transplant centers, show that almost 74 percent of the recipients experienced at least one adverse event in year 1, while 36 percent experienced one or more serious adverse events in the first year post-transplant. Overall, 77 serious adverse events were reported to the Registry, with 22 percent (n = 17) of them classified as life-threatening and 58 percent (n = 45) requiring an inpatient hospitalization. Ninety-five percent of these adverse events were resolved without residual effects. Readers are referred to the Registry’s website, www.citregistry.org, for more information.

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Exenatide Versus Insulin Glargine in Patients with Suboptimally Controlled Type 2 Diabetes. A Randomized Trial. Annals of Internal Medicine. 143(8): 559-569. October 2005.

This article reports on a study that compared the effects of exenatide and insulin glargine (both injectable drugs) on blood glucose control in patients with type 2 diabetes mellitus that is suboptimally controlled with metformin and a sulfonylurea (oral hypoglycemic agents). The 26-week multicenter, open-label, randomized, controlled trial utilized 82 outpatient study centers in 13 countries and included 551 patients with type 2 diabetes and inadequate glycemic control. Inadequate glycemic control is defined as hemoglobin A1c (HbA1c, a measure of blood glucose over time) level ranging from 7.0 percent to 10.0 percent, despite combination metformin and sulfonylurea therapy. Baseline mean HbA1c level was 8.2 percent for patients receiving exenatide and 8.3 percent for those receiving insulin glargine. At week 26, both exenatide and insulin glargine reduced hemoglobin A1c levels by 1.11 percent. Exenatide reduced postprandial glucose excursions (changes in blood glucose levels after a meal) more than insulin glargine, while insulin glargine reduced fasting glucose concentrations more than exenatide. Body weight decreased 2.3 kilograms with exenatide and increased 1.8 kilograms with insulin glargine. Rates of symptomatic hypoglycemia were similar, but nocturnal hypoglycemia occurred less frequently with exenatide. Gastrointestinal symptoms were more common in the exenatide group than in the insulin glargine group, including nausea (57.1 percent versus 8.6 percent), vomiting (17.4 percent versus 3.7 percent) and diarrhea (8.5 percent versus 3.0 percent). The authors conclude that exenatide and insulin glargine achieved similar improvements in overall glycemic control in this patient population. Exenatide was associated with weight reduction and had a higher incidence of gastrointestinal adverse effects than insulin glargine. 3 figures. 3 tables. 34 references.

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Getting Down to Basals. Diabetes Self-Management. 22(4): 60-68. July-August 2005.

Basal insulin is a steady dose of insulin used to match the liver's secretion of glucose into the bloodstream (and to prevent the liver from oversecreting glucose). Basal insulin is necessary for maintaining blood glucose control. This article considers basal insulin requirements, starting doses, fine-tuning basal insulin and pump basal rates and the Somogyi phenomenon. Taking too much basal insulin, or taking it at the wrong times, can result in frequent (and perhaps severe) hypoglycemia, as well as weight gain. Taking too little basal insulin will produce high blood glucose and make it very difficult to set appropriate mealtime bolus doses. The author concludes by encouraging readers to work closely with their endocrinologists or other health care providers to determine their best basal insulin regimen. 2 figures. 2 tables.

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Glucagon-Like Peptide-1 as a Treatment Option for Type 2 Diabetes and Its Role in Restoring Beta-Cell Mass. Diabetes Technology & Therapeutics. 7(4): 651-657. August 2005.

The "incretin effect" describes the enhanced insulin response from orally ingested glucose compared with intravenous glucose leading to identical postprandial plasma glucose excursions. It makes up to 60 percent of the postprandial insulin secretion but is diminished in people with type 2 diabetes. Gastrointestinal hormones promoting the incretin effect are called incretins. This article reviews the use of the incretin called glucagon-like peptide-1 (GLP-1) as a treatment option for type 2 diabetes. The author focuses on the role of GLP-1 in restoring beta-cell mass. The author hypothesizes the GLP-1 may represent an attractive therapeutic method for type 2 diabetes because of its multiple effects, including a slowing of gastric emptying and the simulation of satiety by acting as a transmitter in the central nervous system. GLP-1 also inhibits glucagon secretion and rarely causes hypoglycemia. The author briefly reports on long-acting GLP-1 analogs (Liraglutide and exanadin-4) that are resistant to degradation and a dipeptidyl peptidase IV inhibitor (Vildagliptin), all of which are currently under study. 3 figures. 3 tables. 38 references.

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Glucose Monitoring in Diabetes Care: Evidence, Challenges, and Opportunities. Advanced Studies in Medicine. 5(10): S1100-S1116. December 2005.

Glycemic control, or lack thereof, affects both health care costs and risk of complications from diabetes. This review article outlines the evidence, challenges, and opportunities related to blood glucose monitoring in diabetes care. The authors note that the rate of increase in risk of microvascular complications over the range of blood glucose values (measured by HbA1c, glycosylated hemoglobin) appears to be greater than the rate of risk increase for macrovascular complications. HbA1c is the general primary target for glycemic control, however the authors encourage the individualization of treatment goals in clinical practice. Certain groups, including children, the elderly, and pregnant women, require special consideration. Most patients do not achieve their treatment goals, partly due to a lack of awareness of their glycemic levels and fear of hypoglycemia (low blood glucose levels). The authors stress that patient empowerment involves more than providing the patient with information about diabetes mellitus; it requires practical interventions that facilitate collaborative relationships between health care providers and patients and that enable patients to become responsible for managing their own diabetes. Any member of the diabetes healthcare team can motivate patients by increasing the patient’s knowledge of the disease, and each practitioner should take advantage of opportunities to educate patients and ensure adequate patient contact. The article includes three sidebars that summarize the findings of relevant research studies. 8 figures. 8 tables. 39 references.

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Help Your Child Manage Diabetes: A Parent's Handbook. South Deerfield, MA: Channing Bete Company. 2005. 31 p.

This booklet is designed to help parents of a child newly diagnosed with diabetes understand the basics of caring for a child with diabetes. The booklet covers a description of diabetes, its causes and symptoms; the role of support and emotional health; a plan for diabetes management; blood glucose monitoring; general health approaches, including nutrition and physical activity; diabetes medications, including insulin and its administration and the role of diabetes pills; hypoglycemia and hyperglycemia; diabetes care in the school setting; foot care; and other safety tips. A summary page reminds parents to test the child?s blood glucose, follow a healthy meal plan, encourage the child to be physically active, make sure the child takes all medications, keep good records, and involve the whole family in eating better and staying healthy. The booklet includes a food and medications care chart, a list of resources, a wallet card for the child to carry, and plenty of blank space for individualizing recommendations and management strategies for the child and his or her family. The brochure is illustrated with black-and-white photographs of children and their families, as well as figures and charts designed to increase understanding of the material presented. 5 figures. 2 tables.

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