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1.  Diabetes care and outcomes for American Indians and Alaska natives in commercial integrated delivery systems: a SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) Study 
Objective
To compare cardiovascular disease risk factor testing rates and intermediate outcomes of care between American Indian/Alaska Native (AI/AN) patients with diabetes and non-Hispanic Caucasians enrolled in nine commercial integrated delivery systems in the USA.
Research design and methods
We used modified Poisson regression models to compare the annual testing rates and risk factor control levels for glycated haemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP); number of unique diabetes drug classes; insulin use; and oral diabetes drug medication adherence between insured AI/AN and non-Hispanic white adults with diabetes aged ≥18 in 2011.
Results
5831 AI/AN patients (1.8% of the cohort) met inclusion criteria. After adjusting for age, gender, comorbidities, insulin use, and geocoded socioeconomic status, AI/AN patients had similar rates of annual HbA1c, LDL-C, and SBP testing, and LDL-C and SBP control, compared with non-Hispanic Caucasians. However, AI/AN patients were significantly more likely to have HbA1c >9% (>74.9 mmol/mol; RR=1.47, 95% CI 1.38 to 1.58), and significantly less likely to adhere to their oral diabetes medications (RR=0.90, 95% CI 0.88 to 0.93) compared with non-Hispanic Caucasians.
Conclusions
AI/AN patients in commercial integrated delivery systems have similar blood pressure and cholesterol testing and control, but significantly lower rates of HbA1c control and diabetes medication adherence, compared with non-Hispanic Caucasians. As more AI/ANs move to urban and suburban settings, clinicians and health plans should focus on addressing disparities in diabetes care and outcomes in this population.
doi:10.1136/bmjdrc-2014-000043
PMCID: PMC4246918  PMID: 25452877
American Indian(s); Health Care Delivery
2.  Current Status and Future Prospects for Electronic Point-of-Care Clinical Decision Support in Diabetes Care 
Current diabetes reports  2013;13(2):172-176.
Early efforts to use point-of-care clinical decision support (CDS) were limited to the use of prompts and reminders, which improved test ordering but not intermediate outcomes of care such as glucose, blood pressure, or lipid levels. More sophisticated diabetes CDS tools are now available that use electronic medical record data to provide patient-specific advice on medication use based on previous treatment, distance from goal, and other clinical data. These tools have shown modest but significant improvement in glucose and blood pressure control. Promising next-generation developments will include prioritizing clinical actions that have maximum benefit to a given patient at the point of care and developing effective methods to communicate CDS information to patients to better incorporate patient preferences in care decisions.
doi:10.1007/s11892-012-0350-z
PMCID: PMC3595375  PMID: 23225213
health informatics; electronic health records; chronic disease care; diabetes; hypertension; heart disease; cardiovascular risk
3.  Benefits of Early Hypertension Control on Cardiovascular Outcomes in Patients With Diabetes 
Diabetes Care  2013;36(2):322-327.
OBJECTIVE
To assess the impact of early hypertension (HT) control on occurrence of subsequent major cardiovascular events in those with diabetes and recent-onset HT.
RESEARCH DESIGN AND METHODS
Study subjects were 15,665 adults with diabetes but no diagnosed coronary or cerebrovascular disease at baseline who met standard criteria for new-onset HT. Poisson regression models assessed whether adequate blood pressure control within 1 year of HT onset predicts subsequent occurrence of major cardiovascular events with and without adjustment for baseline Framingham Risk Score (FRS) and other covariates.
RESULTS
Mean age was 51.5 years, and mean blood pressure at HT onset was 136.8/80.8 mmHg. In the year after HT onset, mean blood pressure decreased to 131.4/78.0 mmHg and was <130/80 mmHg in 32.9% of subjects and <140/90 mmHg in 80.2%. Over a mean follow-up of 3.2 years, age-adjusted rates of major cardiovascular events in those with mean 1-year blood pressure measurements of <130/80, 130–139/80–89, and ≥140/90 mmHg were 5.10, 4.27, and 6.94 events/1,000 person-years, respectively (P = 0.004). In FRS-adjusted models, rates of major cardiovascular events were significantly higher in those with mean blood pressure ≥140/90 mmHg in the first year after HT onset (rate ratio 1.30 [95% CI 1.01–1.169]; P = 0.04).
CONCLUSIONS
Failure to adequately control BP within 1 year of HT onset significantly increased the likelihood of major cardiovascular events within 3 years. Prompt control of new-onset HT in patients with diabetes may provide important short-term clinical benefits.
doi:10.2337/dc12-0284
PMCID: PMC3554277  PMID: 22966094
4.  Spontaneous evolution of an unusual cortical malformation in SOX2 anophthalmia syndrome 
Brain malformations such as agenesis and dysgenesis of corpus callosum, pituitary hypoplasia, hypothalamic hamartoma, mesial temporal periventricular heterotopia, and abnormally oriented and misshapen hippocampi have been described with SOX2 gene mutations. A neocortical malformation is presented here in association with SOX2 deletion that over time underwent spontaneous evolution and decrease in size.
doi:10.4103/0972-2327.116924
PMCID: PMC3788299  PMID: 24101835
Cortical malformation; SOX2; anophthalmia
5.  Construction of a Multisite DataLink Using Electronic Health Records for the Identification, Surveillance, Prevention, and Management of Diabetes Mellitus: The SUPREME-DM Project 
Introduction
Electronic health record (EHR) data enhance opportunities for conducting surveillance of diabetes. The objective of this study was to identify the number of people with diabetes from a diabetes DataLink developed as part of the SUPREME-DM (SUrveillance, PREvention, and ManagEment of Diabetes Mellitus) project, a consortium of 11 integrated health systems that use comprehensive EHR data for research.
Methods
We identified all members of 11 health care systems who had any enrollment from January 2005 through December 2009. For these members, we searched inpatient and outpatient diagnosis codes, laboratory test results, and pharmaceutical dispensings from January 2000 through December 2009 to create indicator variables that could potentially identify a person with diabetes. Using this information, we estimated the number of people with diabetes and among them, the number of incident cases, defined as indication of diabetes after at least 2 years of continuous health system enrollment.
Results
The 11 health systems contributed 15,765,529 unique members, of whom 1,085,947 (6.9%) met 1 or more study criteria for diabetes. The nonstandardized proportion meeting study criteria for diabetes ranged from 4.2% to 12.4% across sites. Most members with diabetes (88%) met multiple criteria. Of the members with diabetes, 428,349 (39.4%) were incident cases.
Conclusion
The SUPREME-DM DataLink is a unique resource that provides an opportunity to conduct comparative effectiveness research, epidemiologic surveillance including longitudinal analyses, and population-based care management studies of people with diabetes. It also provides a useful data source for pragmatic clinical trials of prevention or treatment interventions.
doi:10.5888/pcd9.110311
PMCID: PMC3457753  PMID: 22677160
6.  NSAID-induced Antral Ulcers are Associated with Distinct Changes in Mucosal Gene Expression 
Aims
The basis for individual variation in gastroduodenal vulnerability to NSAIDs is not well understood. We aimed to assess whether a gene expression signature was associated with susceptibility to gastroduodenal ulcerations.
Methods
Twenty-five H pylori negative adults were treated for 7 days with naproxen 500 mg BID. Subjects underwent baseline and post-treatment endoscopy, during which biopsies were taken from antrum and duodenum. RNA extraction and cDNA synthesis were performed, followed by PCR of 23 genes relevant to mucosal injury and repair. Fold changes in gene expression were compared between subjects who developed ulcers and those who did not.
Results
Compared to subjects who did not develop ulcers (n=18), subjects who developed antral ulcers (n=7) had significantly greater mucosal up-regulation of interleukin-8 [Fold change = 33.5 (SEM = 18.5) versus −7.7 (3.2)] and of cyclo-oxygenase-2 [2.3 (1.7) versus −10.8 (2.2)]. Conversely, non-ulcer subjects had significantly greater up-regulation of toll-like receptor-4, cyclo-oxygenase-1, and hepatocyte growth factor [14.0 (2.2) vs. −0.8 (1.0), 9.8 (2.4) vs. 0.0 (0.7), and 8.2 (2.6) vs. −2.2 (0.3), respectively].
Conclusions
NSAID-induced antral ulcers are associated with a specific pattern of gastroduodenal mucosal gene expression. These patterns may provide insight into the molecular basis of individual susceptibility to mucosal injury.
doi:10.1111/j.1365-2036.2009.04000.x
PMCID: PMC2831742  PMID: 19309390
7.  An Innovative Approach to Enhancing the Surveillance Capacity of State-based Diabetes Prevention and Control Programs: The Diabetes Indicators and Data Sources Internet Tool (DIDIT) 
Preventing Chronic Disease  2005;2(3):A14.
The Diabetes Indicators and Data Sources Internet Tool (DIDIT) is an interactive Web-based resource with information on 38 diabetes indicators (e.g., diabetes-associated complications, care, lifestyle) and 12 associated data sources frequently used by state diabetes prevention and control programs. This tool is designed to strengthen the ability of states to conduct diabetes surveillance and to promote consistency in defining and tracking indicators across states. In this way, the DIDIT supports one of the 10 essential public health services: the timely and accurate assessment of public health.
In addition to serving as a central repository of information on diabetes surveillance, the DIDIT also allows users to share experiences of using these indicators and data sources in their diabetes surveillance activities, data analysis, and tracking of diabetes-related objectives stated by Healthy People 2010. The DIDIT is an innovative approach to enhancing public health surveillance at the state and national levels.
PMCID: PMC1364523  PMID: 15963316
9.  Variation in diabetes care by age: opportunities for customization of care 
BMC Family Practice  2003;4:16.
Background
The quality of diabetes care provided to older adults has usually been judged to be poor, but few data provide direct comparison to other age groups. In this study, we hypothesized that adults age 65 and over receive lower quality diabetes care than adults age 45–64 years old.
Methods
We conducted a cohort study of members of a health plan cared for by multiple medical groups in Minnesota. Study subjects were a random sample of 1109 adults age 45 and over with an established diagnosis of diabetes using a diabetes identification method with estimated sensitivity 0.91 and positive predictive value 0.94. Survey data (response rate 86.2%) and administrative databases were used to assess diabetes severity, glycemic control, quality of life, microvascular and macrovascular risks and complications, preventive care, utilization, and perceptions of diabetes.
Results
Compared to those aged 45–64 years (N = 627), those 65 and older (N = 482) had better glycemic control, better health-related behaviors, and perceived less adverse impacts of diabetes on their quality of life despite longer duration of diabetes and a prevalence of cardiovascular disease twice that of younger patients. Older patients did not ascribe heart disease to their diabetes. Younger adults often had explanatory models of diabetes that interfere with effective and aggressive care, and accessed care less frequently. Overall, only 37% of patients were simultaneously up-to-date on eye exams, foot exams, and glycated hemoglobin (A1c) tests within one year.
Conclusion
These data demonstrate the need for further improvement in diabetes care for all patients, and suggest that customisation of care based on age and explanatory models of diabetes may be an improvement strategy that merits further evaluation.
doi:10.1186/1471-2296-4-16
PMCID: PMC280680  PMID: 14585101

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