The Clinical and Genetic Diversity of Thyroid Hormone Resistance: Four Clinical Vignettes.

Introduction: Resistance to thyroid hormones (RTH) is a rare but important genetic cause of decreased peripheral tissue responses to the actions of thyroxine. Most RTH cases are caused by mutations in thyroid hormone receptor β (TRβ, THRB), while a few are caused by mutations in thyroid hormone receptor α (TRα, THRA). RTH is clinically heterogeneous, and the biochemical features are often confusing, resulting in misdiagnoses, mismanagement, and life-long consequences for affected individuals.

Alpelisib-Induced Diabetic Ketoacidosis in a Patient With Metastatic Breast Cancer.

We report the case of a 45-year-old woman with metastatic breast cancer who started treatment with alpelisib nine days before developing diabetic ketoacidosis (DKA). At the time of DKA diagnosis, blood tests showed a capillary blood glucose of 30 mmol/L, serum carbon dioxide level of 11 mmol/L, an anion gap of 25 mEq/L, and a glycated hemoglobin A1C (HbA1c) level of 6.4% (50 mmol/mol).

Epidemiology of type 2 diabetes in the Middle East and North Africa: Challenges and call for action.

Type 2 diabetes continues to be a serious and highly prevalent public health problem worldwide. In 2019, the highest prevalence of diabetes in the world at 12.2%, with its associated morbidity and mortality, was found in the Middle East and North Africa region.

Diabetes management in urban African Americans: review of a public hospital experience.

Objective: To review characteristics of an urban (primarily African American) diabetes patient population and discuss experience with treatment strategies, we summarize key retrospective and prospective analyses conducted during 15 years.

Results: Severe socioeconomic and personal barriers to diabetes care were often seen in the population. An atypical presentation of diabetic ketoacidosis was observed and extensively studied.

Use of a glucose algorithm to direct diabetes therapy improves A1C outcomes and defines an approach to assess provider behavior.

Purpose: The purpose of this study was to determine whether an algorithm that recommended individualized changes in therapy would help providers to change therapy appropriately and improve glycemic control in their patients.

Methods: The algorithm recommended specific doses of oral agents and insulin based on a patient's medications and glucose or A1C levels at the time of the visit. The prospective observational study analyzed the effect of the algorithm on treatment decisions and A1C levels in patients with type 2 diabetes.

An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: Improving Primary Care of African Americans with Diabetes (IPCAAD) 8.

Background: Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated--clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control.

Limited health care access impairs glycemic control in low income urban African Americans with type 2 diabetes.

Limited access to health care is associated with adverse outcomes, but few studies have examined its effect on glycemic control in minority populations. Our observational cross-sectional study examined whether differences in health care access affected hemoglobin A1c (HbA1c) levels in 605 patients with diabetes (56% women; 89% African American; average age, 50 years; 95% with type 2 diabetes) initially treated at a municipal diabetes clinic. Patients who had difficulty obtaining care had higher A1c levels (9.

Diabetes management by residents in training in a municipal hospital primary care site (IPCAAD 2).

Purpose: Since diabetes is largely a primary care problem but we know little about management by residents in training--the primary care practitioners of the future--we examined surrogate outcomes reflective of their performance.

Methods: A seven-week observational study was conducted in a typical training site- a municipal hospital internal medicine resident "continuity" (primary care) clinic in a large, academic, university-affiliated training program. We evaluated control of glucose, blood pressure, and lipids; screening for proteinuria; and use of aspirin relative to national standards.

An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7.

Objective: Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes.

Research Design And Methods: A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center.

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.

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.

Evolving demographics and disparities in an urban diabetes clinic: implications for diabetes education and treatment.

Objectives: To compare demographics and disease characteristics in a multiethnic diabetes clinic population to identify changes over time.

Design: Analysis and comparison of demographics and disease characteristics of diabetes patients, recorded electronically at intake over 10 years.

Setting: An urban outpatient diabetes clinic.

Patient adherence improves glycemic control.

Purpose: The purpose of this study was to assess the influence of appointment keeping and medication adherence on HbA1c.

Methods: A retrospective evaluation was performed in 1560 patients with type 2 diabetes who presented for a new visit to the Grady Diabetes Clinic between 1991 and 2001 and returned for a follow-up visit and HbA1c after 1 year of care. Appointment keeping was assessed by the number of scheduled intervening visits that were kept, and medication adherence was assessed by the percentage of visits in which self-reported diabetes medication use was as recommended at the preceding visit.

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.

Little time for diabetes management in the primary care setting.

Purpose: This study was conducted to determine how time is allocated to diabetes care.

Methods: Patients with type 2 diabetes who were receiving care from the internal medicine residents were shadowed by research nurses to observe the process of management. The amount of time spent with patients and the care provided were observed and documented.

Inpatient to outpatient transfer of care in urban patients with diabetes: patterns and determinants of immediate postdischarge follow-up.

Background: A key opportunity for continuing diabetes care is to assure outpatient follow-up after hospitalization. To delineate patterns and factors associated with having an ambulatory care visit, we examined immediate postdischarge follow-up among a cohort of urban, hospitalized patients with diabetes mellitus.

Methods: Retrospective study of 658 inpatients of a municipal hospital.

Utility of casual postprandial glucose levels in type 2 diabetes management.

Objective: Because readily available glycemic indicators are needed to guide clinical decision-making for intensification of diabetes therapy, our goals were to define the relationship between casual postprandial plasma glucose (cPPG) levels and HbA(1c) in patients with type 2 diabetes and to determine the predictive characteristics of a convenient glucose cutoff.

Research Design And Methods: We examined the relationship between cPPG levels (1-4 h post meal) and HbA(1c) levels in 1,827 unique patients who had both determinations during a single office visit.

Results: The population studied was predominantly African American and middle-aged, with average cPPG of 201 mg/dl and HbA(1c) of 8.

A simple meal plan emphasizing healthy food choices is as effective as an exchange-based meal plan for urban African Americans with type 2 diabetes.

Objective: To compare a simple meal plan emphasizing healthy food choices with a traditional exchange-based meal plan in reducing HbA(1c) levels in urban African Americans with type 2 diabetes.

Research Design And Methods: A total of 648 patients with type 2 diabetes were randomized to receive instruction in either a healthy food choices meal plan (HFC) or an exchange-based meal plan (EXCH) to compare the impact on glycemic control, weight loss, serum lipids, and blood pressure at 6 months of follow-up. Dietary practices were assessed with food frequency questionnaires.

Rapid A1c availability improves clinical decision-making in an urban primary care clinic.

Objective: Failure to meet goals for glycemic control in primary care settings may be due in part to lack of information critical to guide intensification of therapy. Our objective is to determine whether rapid-turnaround A1c availability would improve intensification of diabetes therapy and reduce A1c levels in patients with type 2 diabetes.

Research Design And Methods: In this prospective controlled trial, A1c was determined on capillary glucose samples and made available to providers, either during ("rapid") or after ("routine") the patient visit.

Association of younger age with poor glycemic control and obesity in urban african americans with type 2 diabetes.

Background: Type 2 diabetes mellitus is highly prevalent in minority populations in the United States. We studied the relationship of age to glycemic control in a predominantly urban African American population with type 2 diabetes.

Methods: We selected all patients with type 2 diabetes who were enrolled in the Grady Diabetes Clinic, Atlanta, Ga, between April 1, 1991, and December 31, 1998, and had a hemoglobin A(1c) (HbA(1c)) level measured at their initial visit and at follow-up 5 to 12 months later (n = 2539).

The Improving Primary Care of African Americans with Diabetes (IPCAAD) project: rationale and design.

African Americans have an increased burden of both diabetes and diabetes complications. Since many patients have high glucose levels novel interventions are needed, especially for urban patients with limited resources. In the Grady Diabetes Clinic in Atlanta, a stepped care strategy improves metabolic control.

The impact of outpatient diabetes management on serum lipids in urban African-Americans with type 2 diabetes.

Objective: Treating dyslipidemia in diabetic patients is essential, particularly among minority populations with increased risk of complications. Because little is known about the impact of outpatient diabetes management on lipid outcomes, we examined changes in lipid profiles in urban African-Americans who attended a structured diabetes care program.

Research Design And Methods: A retrospective analysis of initial and 1-year follow-up lipid values was conducted among patients selected from a computerized registry of an urban outpatient diabetes clinic.

Clinical inertia.

Medicine has traditionally focused on relieving patient symptoms. However, in developed countries, maintaining good health increasingly involves management of such problems as hypertension, dyslipidemia, and diabetes, which often have no symptoms. Moreover, abnormal blood pressure, lipid, and glucose values are generally sufficient to warrant treatment without further diagnostic maneuvers.

Hypoglycemia in patients with type 2 diabetes mellitus.

Background: Although hypoglycemia is the most common complication of intensive diabetes therapy, there is little information about risk factors for hypoglycemia in patients with type 2 diabetes mellitus.

Objective: To determine the prevalence and predisposing factors for hypoglycemia in patients with type 2 diabetes.

Methods: Retrospective, cross-sectional analysis set in an outpatient specialty diabetes clinic.