Biomedical subjects

Richard M Hoffman

Publications and source records attributed to Richard M Hoffman.

At least 19 recordsLinked to original sources

PubMed2006

Self-reported volume of radical prostatectomies among urologists in the USA.

OBJECTIVE: To evaluate the variability in the volume of radical retropubic prostatectomy (RP) performed by urologists in the USA, and the physician characteristics that predict RP volume, as previous studies showed that individual surgeon volume for RP is associated with clinical outcomes. METHODS: In a nationwide, representative survey of 2000 urologists who treat prostate carcinoma in the USA, we asked respondents to indicate a numerical range of RPs they perform each year (none, 1-10, 11-30, and >30, the last which we defined as 'high volume'). We then identified characteristics of the provider and practice associated with a high volume of RPs. Supplementing survey results with other national data, we estimated the proportion of all RPs in the USA performed by 'high-volume' urologists. RESULTS: The survey response rate was 66.1% (1313 urologists) with no differences between the respondents and non-respondents for the measured demographic variables. Among urologists who performed RPs (89.1% of the sample), 37.3% did < or = 10, 46.9% 11-30 and 15.8% >30 RPs/year. Academic and urological oncology fellowship-trained urologists were, respectively, 41% and 27% more likely than private-practice and non-fellowship-trained urologists to have a high volume of RPs. Of all RPs performed yearly in the USA, only an estimated 46.1% were by high-volume urologists. CONCLUSION: A significant proportion of urologists report a RP volume that might be associated with higher rates of cardiac, respiratory, vascular, wound-healing, and genitourinary complications. Further study is needed to characterize the possible relationships between RP volume and tumour recurrence, survival, and long-term erectile dysfunction and incontinence.

Erectile Dysfunction↗

PubMed2006

Racial and ethnic disparities in the control of cardiovascular disease risk factors in Southwest American veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study.

BACKGROUND: Racial/ethnic disparities in cardiovascular disease complications have been observed in diabetic patients. We examined the association between race/ethnicity and cardiovascular disease risk factor control in a large cohort of insulin-treated veterans with type 2 diabetes. METHODS: We conducted a cross-sectional observational study at 3 Veterans Affairs Medical Centers in the American Southwest. Using electronic pharmacy databases, we randomly selected 338 veterans with insulin-treated type 2 diabetes. We collected medical record and patient survey data on diabetes control and management, cardiovascular disease risk factors, comorbidity, demographics, socioeconomic factors, psychological status, and health behaviors. We used analysis of variance and multivariate linear regression to determine the effect of race/ethnicity on glycemic control, insulin treatment intensity, lipid levels, and blood pressure control. RESULTS: The study cohort was comprised of 72 (21.3%) Hispanic subjects (H), 35 (10.4%) African Americans (AA), and 226 (67%) non-Hispanic whites (NHW). The mean (SD) hemoglobin A1c differed significantly by race/ethnicity: NHW 7.86 (1.4)%, H 8.16 (1.6)%, AA 8.84 (2.9)%, p = 0.05. The multivariate-adjusted A1c was significantly higher for AA (+0.93%, p = 0.002) compared to NHW. Insulin doses (unit/day) also differed significantly: NHW 70.6 (48.8), H 58.4 (32.6), and AA 53.1 (36.2), p < 0.01. Multivariate-adjusted insulin doses were significantly lower for AA (-17.8 units/day, p = 0.01) and H (-10.5 units/day, p = 0.04) compared to NHW. Decrements in insulin doses were even greater among minority patients with poorly controlled diabetes (A1c > or = 8%). The disparities in glycemic control and insulin treatment intensity could not be explained by differences in age, body mass index, oral hypoglycemic medications, socioeconomic barriers, attitudes about diabetes care, diabetes knowledge, depression, cognitive dysfunction, or social support. We found no significant racial/ethnic differences in lipid or blood pressure control. CONCLUSION: In our cohort, insulin-treated minority veterans, particularly AA, had poorer glycemic control and received lower doses of insulin than NHW. However, we found no differences for control of other cardiovascular disease risk factors. The diabetes treatment disparity could be due to provider behaviors and/or patient behaviors or preferences. Further research with larger sample sizes and more geographically diverse populations are needed to confirm our findings.

Black or African American↗

PubMed2006

Viewpoint: limiting prostate cancer screening.

Prostate cancer screening is controversial, and major professional associations offer differing screening guidelines. The author addresses 3 key issues about prostate cancer screening: 1) the prostate-specific antigen (PSA) criteria to recommend a prostate biopsy, 2) the appropriate age to start screening, and 3) the appropriate age to stop screening. The author argues, on the basis of evidence published since 2000, that data supporting the efficacy of PSA screening remain unconvincing. The author recommends that screening should not be expanded to include average-risk men younger than age 50 years or older than age 75 years and that a PSA threshold below 4.0 ng/mL should not be used to trigger biopsy referral.

Adult↗

PubMed2006

Health outcomes in older men with localized prostate cancer: results from the Prostate Cancer Outcomes Study.

PURPOSE: We compared health-related quality-of-life (HRQOL) outcomes and survival of men with localized prostate cancer who received aggressive treatment with those receiving conservative management. METHODS: We conducted a population-based cohort study of men aged 75 to 84 years when diagnosed with a clinically localized cancer in 1994 or 1995. We used medical record abstractions and patient surveys to obtain clinical and HRQOL data at diagnosis and 24-month follow-up. We used a propensity score method to adjust for baseline differences between men treated with radical prostatectomy or radiation therapy (n = 175) and men who received hormone therapy or no treatment (n = 290). Propensity scores were used in regression analyses comparing HRQOL outcomes between treatment groups. Overall and disease-specific survivals were estimated with multivariate proportional hazards models. RESULTS: At 24 months following diagnosis, aggressively treated men were more likely to report daily urinary leakage (odds ratio [OR] = 2.9, 95% confidence interval [CI] 1.2-7.0) and to be bothered by urinary problems (OR = 5.1, 95% CI, 1.3-9.1) and sexual problems (OR = 2.8, 95% CI, 1.2-6.3). The adjusted disease-specific mortality hazard ratio was 0.43 (95% CI, 0.15, 1.28), favoring aggressive treatment. However, the absolute 5-year disease-specific survival difference was only 6% (98% vs 92%). Over 80% of all deaths were from other causes. CONCLUSIONS: Aggressive treatment was associated with significant decreases in disease-specific HRQOL. However, men who were aggressively treated for localized cancer had a minimally reduced absolute risk of dying from prostate cancer. Physicians and older patients should consider these outcomes in making decisions about screening and treatment.

Age Factors↗

PubMed2006

The influence of patient race and social vulnerability on urologist treatment recommendations in localized prostate carcinoma.

BACKGROUND: In localized prostate carcinoma (PCa), many studies have found that black subjects receive radical prostatectomy (RP) less often than white subjects. Such disparities involve barriers to health care, comorbid illnesses, tumor characteristics, and patient preferences. It is unclear whether differences in urologist treatment recommendations also might play a role. METHODS: Using a randomized, 2 x 2 factorial design, we presented 2000 urologists with a clinical vignette and asked them to recommend treatment of a healthy 70-year-old patient with low-risk, clinically localized PCa. Options included either RP, external beam radiotherapy, brachytherapy, cryotherapy, observation, or hormonal therapy. There were 2 variables within 4 otherwise-identical versions of the vignette: 1) patient race (black vs. white) and 2) social vulnerability (middle-income and married vs. low-income and widowed). We used multivariable logistic regression to model the effects of patient race, social vulnerability, and their interaction on recommendations for RP versus radiotherapy. RESULTS: The response rate was 66.1% (n = 1313). Race and social vulnerability interacted (P = 0.05) such that the highly vulnerable black patient received an RP recommendation 14.4% less often than his less vulnerable counterpart; the difference between the 2 white patients was 4.2%. DISCUSSION: Race interacts with social vulnerability to influence urologist recommendations for RP. Because PCa tends to be more lethal in blacks, urologists may view such patients as good candidates for RP. However, black race may amplify perceptions of social vulnerability, heightening urologists' concerns about poor surgical outcomes and follow-up. These findings affirm the importance of modeling interactions between race/ethnicity and other social variables in health disparities research.

Black or African American↗

PubMed2006

Trends and predictors of aggressive therapy for clinical locally advanced prostate carcinoma.

OBJECTIVE: To determine the patterns and predictors of aggressive local therapies for patients with clinically advanced (cT3) prostate carcinoma, as the USA National Cancer Institute considers external beam radiotherapy (EBRT) to be the most appropriate treatment for these patients, and currently there is less evidence supporting the use of radical prostatectomy (RP). PATIENTS AND METHODS: We used the Surveillance, Epidemiology and End Results (SEER) cancer registries to identify patients diagnosed with cT3 disease between 1995 and 2001. Sociodemographic and clinical data included patient age, race/ethnicity, marital status, SEER registry, year of diagnosis, tumour stage and grade, and treatment. Multivariate logistic regression was used to identify significant predictors of receiving (i) RP vs EBRT, (ii) any aggressive local treatment (RP or EBRT) or no treatment. RESULTS: Between 1995 and 2001, the proportion of men receiving aggressive local therapy for cT3 disease increased by 11% (58.4% to 69.4%), with a 20% increase in EBRT (40.3% to 60.2%) but a decline by half in RP (18.1% to 9.3%). Younger age was the strongest predictor of receiving RP rather than EBRT, and younger age with being married being a predictor of receiving aggressive local therapy (adjusted relative risk for marriage 1.33, 95% confidence interval 1.18-1.87). Black men were significantly less likely than non-Hispanic white men to receive aggressive therapy, with a relative risk of 0.56 (0.45-0.69). CONCLUSION: By 2001, 70% of patients with cT3 disease were receiving aggressive local therapy, with EBRT 6.5 times more common than RP. Clinical trials are needed to rigorously assess the effects of different local treatment strategies on clinical outcomes in men with cT3 prostate carcinoma.

Aged↗

PubMed2005

Differences between men with screening-detected versus clinically diagnosed prostate cancers in the USA.

BACKGROUND: The advent of prostate specific antigen (PSA) testing in the United States of America (USA) has led to a dramatic increase in the incidence of prostate cancer in the United States as well as the number of men undergoing aggressive treatment with radical prostatectomy and radiation therapy. We compared patient characteristics and treatment selection between American men with screening-detected versus clinically diagnosed prostate cancers. METHODS: We evaluated 3,173 men with prostate cancer in the USA. Surveys and medical records provided information on demographics, socioeconomic status, comorbidities, symptoms, tumor characteristics, and treatment. We classified men presenting with symptoms of advanced cancer - bone pain, weight loss, or hematuria - as "clinically diagnosed"; asymptomatic men and those with only lower urinary tract symptoms were considered "screening-detected." We used multivariate analyses to determine whether screening predicted receiving aggressive treatment for a clinically localized cancer. RESULTS: We classified 11% of cancers as being clinically diagnosed. Men with screening-detected cancers were more often non-Hispanic white (77% vs. 65%, P < 0.01), younger (36% < 65 years vs. 25%, P or= high school vs. 67%, P < 0.01), healthier (18% excellent health vs. 10%, P < 0.01), and diagnosed with localized disease (90% vs. 75%, P < 0.01). Men with screening-detected localized cancers more often underwent aggressive treatment, 76% vs. 70%, P = 0.05. CONCLUSION: Most cancers were detected by screening in this American cohort. Appropriately, younger, healthier men were more likely to be diagnosed by screening. Minority status and lower socio-economic status appeared to be screening barriers. Screening detected earlier-stage cancers and was associated with receiving aggressive treatment.

Aged↗

PubMed2005

5-year urinary and sexual outcomes after radical prostatectomy: results from the prostate cancer outcomes study.

PURPOSE: Prior studies of postoperative outcomes following radical prostatectomy have been limited by selection bias and short-term followup. In this study we assessed temporal changes in urinary and sexual function up to 5 years following radical prostatectomy in a population based cohort. MATERIALS AND METHODS: A sample of 1,288 men with localized prostate cancer who underwent radical prostatectomy and completed a baseline survey within 6 to 12 months of diagnosis were included in the analysis. Two and 5-year functional and quality of life data were collected, as was information on the use of erectile aids. Temporal functional changes and potentially confounding or modifying factors were assessed using longitudinal regression models. RESULTS: Of these men 14% reported frequent urinary leakage or no urinary control 60 months after diagnosis, which was slightly higher than the 10% reporting incontinence at 24 months (p = 0.007). At 60 months 28% of the men had erections firm enough for intercourse compared with 22% at 24 months (p = 0.003). Sildenafil was the most commonly used erectile aid (43% ever used) and 45% of users reported that it helped "somewhat" or "a lot." CONCLUSIONS: Urinary and sexual dysfunction were common 5 years following radical prostatectomy in this large, community based cohort of prostate cancer survivors. While a small minority of subjects experienced changes in urinary or sexual function between years 2 and 5 after prostatectomy, functional outcomes remained relatively stable in the majority of participants.

Adult↗

PubMed2005

Treatment of erectile dysfunction following therapy for clinically localized prostate cancer: patient reported use and outcomes from the Surveillance, Epidemiology, and End Results Prostate Cancer Outcomes Study.

PURPOSE: Erectile dysfunction (ED) persists for years following curative therapies for clinically localized prostate cancer. We report use and treatment outcomes in a 5-year interval in a population based cohort from the Surveillance, Epidemiology, and End Results Prostate Cancer Outcomes Study. MATERIALS AND METHODS: A sample of 1,977 men with localized prostate cancer who received external beam radiation therapy or radical prostatectomy in 1994 to 1995 were surveyed for 5 outcome measures of ED treatment, namely treatment, perceived helpfulness, erectile sufficiency, sexual activity frequency and erection maintenance. Subjects were surveyed 6, 12, 24 and 60 months after prostate cancer diagnosis. RESULTS: Overall 50.5% of men ever used ED treatment. The use of ED treatments increased during the study course. Subject age, regular sexual partner and baseline sexual activity were factors positively associated with ED treatments. While it was used uncommonly (1.9%), a penile prosthesis was perceived as the most helpful ED treatment (helped a lot in 52% of respondents). Sildenafil helped a lot in 12% of respondents. Erectile fullness, erection maintenance and sexual activity frequency were modestly improved in men using ED treatment compared with those in men not using ED treatment. CONCLUSIONS: Approximately half of the patients in this population based cohort of men used ED treatment during the 5 years following prostate cancer diagnosis. Men using ED treatments had modest improvement in sexual function compared with men that in who did not receive ED treatment at 60 months. More effective treatments for ED following local therapy for prostate cancer are needed.

3',5'-Cyclic-GMP Phosphodiesterases↗

PubMed2005

Reliability and validity of the DCP among hispanic veterans.

The Diabetes Care Profile (DCP) was designed to measure psychosocial factors related to diabetes and its treatment. This study sought to determine the reliability and validity of the DCP in Hispanic veterans with Type 2 diabetes. Hispanic (n=81) and non-Hispanic White (n=238) patients were recruited at three southwestern VA hospitals. Scale reliabilities calculated by Cronbach's coefficient alpha revealed reliabilities ranging from .54 to .97 in Hispanics and .63 to .95 in non-Hispanic Whites. Only one scale, Monitoring Barriers, differed significantly between the two patient groups. Mean values on the DCP scales were consistent within and across ethnicities lending support for construct validity of the DCP in Hispanics. Convergent validity was also supported for DCP scales within the Hispanic patients as evidenced by correlations in expected directions with external measures.

Aged↗

PubMed2004

New Mexico's capacity for increasing the prevalence of colorectal cancer screening with screening colonoscopies.

INTRODUCTION: Colorectal cancer screening rates are low throughout the United States. Colonoscopy has been recommended as a cost-effective strategy for colorectal cancer screening and prevention. We evaluated New Mexico's capacity to increase the prevalence of colorectal cancer screening using colonoscopy. METHODS: We identified New Mexican gastroenterologists from state licensing data and from endoscopic manufacturers. We surveyed gastroenterologists on their weekly number of colonoscopies, capacity for additional screening colonoscopies, and barriers to increasing capacity. We used census data, published data on the yield of screening colonoscopy, and professional society guidelines for cancer/polyp surveillance to estimate the additional colonoscopies required to increase the state's prevalence of endoscopic screening. RESULTS: Forty gastroenterologists, representing all 11 group practices in the state, and nine of 12 solo practitioners responded. They estimated that their weekly procedure capacity could be increased by 41%, from 832 to 1174 colonoscopies. We estimated an annual capacity increase of 14,880 procedures, which could increase the prevalence of endoscopic colorectal cancer screening from the current 35% to about 50% over five years. Lack of support staff, space, and physicians were barriers to increasing screening. CONCLUSION: Implementing a screening colonoscopy strategy could achieve the goal of a higher level of colorectal screening. However, achieving more universal screening would require additional testing modalities.

Colonoscopy↗

PubMed2004

Cross-sectional and longitudinal comparisons of health-related quality of life between patients with prostate carcinoma and matched controls.

BACKGROUND: Prostate carcinoma and treatments affect health-related quality of life (HRQOL). The authors prospectively compared prostate and general HRQOL between prostate carcinoma cases and an age-matched and ethnicity-matched control group. METHODS: The case cohort consisted of 293 men with localized prostate carcinoma who were selected randomly from the population-based New Mexico Tumor Registry, and the control cohort consisted of 618 men who were selected randomly from administrative databases and matched for age and ethnicity. Subjects completed a baseline survey of demographics, socioeconomic status, comorbidity, and prostate and general HRQOL. Also, 210 cases (71.7%) and 421 controls (67.8%) completed a follow-up survey 5 years later. Multinomial logistic regression models compared baseline characteristics as well as 5-year general HRQOL outcomes measured by selected domains of the Medical Outcomes Study SF-36. The authors used a mixed-model repeated-measures analysis of variance and multinomial regression analyses to compare longitudinal changes in urinary, bowel, and sexual function between groups. RESULTS: At baseline, patients with prostate carcinoma had better urinary control and sexual function than controls. Over 5 years, sexual function declined significantly among controls, although urinary function remained stable. However, patients with cancer subsequently reported significant declines in both domains and were left with much worse function and more bother than controls. Bowel function and general HRQOL were similar for both groups at follow-up. CONCLUSIONS: Prostate carcinoma treatment led to significant 5-year declines in urinary and sexual function that far exceeded age-related changes in controls. Patients with cancer had significantly worse function and more bother than controls for these disease-specific domains of HRQOL. Bowel function and general HRQOL were not affected by cancer status.

Cross-Sectional Studies↗

PubMed2004

Racial/Ethnic differences in functional outcomes in the 5 years after diagnosis of localized prostate cancer.

PURPOSE: We investigated racial/ethnic differences in functional outcomes up to 5 years after diagnosis among men with aggressively treated localized prostate cancer. PATIENTS AND METHODS: Patients were from the Prostate Cancer Outcomes Study, a population-based cohort study that surveyed patients at 6, 12, 24, and 60 months after diagnosis. Analyses were stratified by primary treatment. Racial/ethnic differences at each time point were assessed using Generalized Estimating Equations, adjusting for pretreatment function, age at diagnosis, secondary treatment, and other confounders. An adjusted summary score for each functional domain was calculated for each time period. RESULTS: Patients included 1,475 non-Hispanic white, 321 African-American, and 279 Hispanic prostate cancer patients. After 60 months, among prostatectomy patients, African-Americans had significantly higher sexual function scores than non-Hispanic whites (43.9 v 36.1; P = .02), but were more likely to have a moderate to big problem with sexual function (50.6% v 44.4%; P = .04). African-Americans also had higher urinary function scores at 5 years than non-Hispanic whites (78.5 v 72.4; P = .04) and were less likely to have problems with incontinence. Changes in sexual and bowel function after radiotherapy showed no significant racial/ethnic differences. CONCLUSION: This long-term cohort study found that, among prostatectomy patients, African-Americans had better recovery of sexual and urinary function at 60 months after diagnosis that was likely to be of mild clinical significance, despite reporting more problems with sexual function than non-Hispanic whites. More study is necessary to understand reasons for these differences. In contrast, no racial/ethnic differences in recovery from radiotherapy were found.

Black or African American↗

PubMed2004

Latent variable modelling of recovery trajectories: sexual function following radical prostatectomy.

As treatments improve and survival time lengthens, the course of recovery and long-term quality of life (QoL) is of greater interest. The application of latent class growth models to longitudinal QoL data provides unique insights into recovery that are not evident with marginal analyses. We examine this approach in the context of a large population-based observational study. This is the first attempt to characterize individuals' recovery over time following prostate cancer surgery, and to determine factors associated with varying recovery experiences of prostate cancer patients. Four major patterns emerged that illustrate typical patterns of recovery following radical prostatectomy. Given a man's baseline data, this method produces estimates of the probability of belonging to each recovery class. The method is presented as a useful tool for identifying hypotheses associated with recovery and potential antecedents of importance.

Erectile Dysfunction↗

PubMed2004

Five-year outcomes after prostatectomy or radiotherapy for prostate cancer: the prostate cancer outcomes study.

BACKGROUND: Men treated for clinically localized prostate cancer with either radical prostatectomy or external beam radiotherapy usually survive many years with the side effects of these treatments. We present treatment-specific quality-of-life outcomes for prostate cancer patients 5 years after initial diagnosis. METHODS: The cohort consisted of men aged 55-74 years who were newly diagnosed with clinically localized prostate cancer in 1994-1995 and were treated with radical prostatectomy (n = 901) or external beam radiotherapy (n = 286). We used clinical and quality-of-life data previously collected at the time of diagnosis (i.e., baseline) and at the 2-year follow-up and data newly collected at 5 years after diagnosis to compare urinary, bowel, and sexual function and to examine temporal changes in those functions. Odds ratios (ORs) and adjusted percentages were calculated by logistic regression. All statistical tests were two-sided. RESULTS: At 5 years after diagnosis, overall sexual function declined in both groups to approximately the same level. However, at 5 years after diagnosis, erectile dysfunction was more prevalent in the radical prostatectomy group than in the external beam radiotherapy group (79.3% versus 63.5%; OR = 2.5, 95% confidence interval [CI] = 1.6 to 3.8). Approximately 14%-16% of radical prostatectomy and 4% of external beam radiotherapy patients were incontinent at 5 years (OR = 4.4, 95% CI = 2.2 to 8.6). Bowel urgency and painful hemorrhoids were more common in the external beam radiotherapy group than in the radical prostatectomy group. All of these differences remained statistically significant after adjustment for confounders and for differences between treatment groups in some baseline characteristics. CONCLUSIONS: At 5 years after diagnosis, men treated with radical prostatectomy for localized prostate cancer continue to experience worse urinary incontinence than men treated with external beam radiotherapy. However, the two treatment groups were more similar to each other with respect to overall sexual function, mostly because of a continuing decline in erectile function among the external beam radiotherapy patients between years 2 and 5.

Aged↗

PubMed2004

A probabilistic model for predicting hypoglycemia in type 2 diabetes mellitus: The Diabetes Outcomes in Veterans Study (DOVES).

BACKGROUND: To develop and validate a method for estimating hypoglycemia risk in stable, insulin-treated subjects with type 2 diabetes mellitus. METHODS: Subjects (n = 195) monitored their blood glucose levels 4 times daily for 8 weeks. An 8-week mean blood glucose value (GLUMEAN) with standard deviation (GLUSD) was derived for each patient. Subjects were then randomly allocated to a derivation or validation set. For the derivation set, we developed a logistic function based on GLUMEAN and GLUSD to describe the 8-week risk of hypoglycemia (blood glucose < or =60 mg/dL [3.3 mmol/L]). This function was used to assign a predicted probability of hypoglycemia to each subject in the validation set. Subjects were assigned to risk quartiles and followed up for up to 52 weeks. RESULTS: We evaluated 195 subjects, 95% of whom were men and 69% of whom were non-Hispanic white. For 72 derivation subjects, GLUMEAN and GLUSD were highly influential determinants of hypoglycemia during intensified monitoring. The 123 validation subjects were followed up for 39.7 +/- 7.1 weeks (mean +/- SD). The occurrence of long-term hypoglycemia differed significantly across risk quartiles (19.4%, 36.7%, 61.3%, and 77.4%, respectively; P<.001). Receiver operating characteristic curve analysis showed that the area for the probability function (0.746 +/- 0.046) was significantly higher than the area for hemoglobin A1c (0.549 +/- 0.052) because their 95% confidence intervals did not overlap. The function also identified subjects who developed long-term hypoglycemia at a rate exceeding the median frequency. CONCLUSIONS: Self-monitoring of blood glucose is superior to hemoglobin A1c measurement in predicting long-term hypoglycemia in persons with type 2 diabetes. The risk of hypoglycemia associated with treatment intensification may be offset by strategies that reduce glucose variability.

Adult↗

PubMed2004

Hypoglycemia in type 2 diabetes: a critical review.

Hypoglycemia is the most important barrier to tight glycemic control. Although severe hypoglycemia is uncommon, milder events can occur so often that they represent a deterrent to intensifying treatment. High-risk patient behaviors are the most important cause for episodes for which a cause can be identified. Because symptoms are an unreliable way of establishing the diagnosis, SMBG should be considered for the patients at highest risk, particularly as they approach their glycemic targets. SMBG is superior to HbA1c in forecasting the hypoglycemia rate because it provides information about glucose variability--an independent risk factor. Patient education and medication changes are potential ways of reducing the hypoglycemia rate. However, it remains to be proven that patient education is beneficial in this regard.

Circadian Rhythm↗

PubMed2004

Factors affecting hypoglycemia awareness in insulin-treated type 2 diabetes: The Diabetes Outcomes in Veterans Study (DOVES).

OBJECTIVE: To identify clinical factors that affect hypoglycemia perception in type 2 diabetes. METHODS: Prospective observational study of 344 insulin-treated subjects randomly selected from pharmacy records at three large medical centers. At entry, subjects underwent an extensive psychological evaluation and then monitored their blood glucoses in their usual fashion for up to 52 weeks using a glucose meter capable of storing 1000 readings. For blood glucoses <or=3.33 mmol/l (60 mg/dl), subjects recorded the severity of symptoms in a log book. Symptoms were scored '0' if they were asymptomatic, '1' for symptoms that were mild-to-moderate, and '2' if the subject had a diminished level of consciousness or required the assistance of others. A mean blood glucose and mean symptom score were calculated for all hypoglycemic episodes detected by each patient. RESULTS: One hundred seventy-six subjects (51.2%) had a median of 4.5 hypoglycemic events during 42.5+/-8.0 weeks of follow-up. The mean hypoglycemic blood glucoses and mean symptom scores were modestly correlated (r=0.153; P=0.043). After adjusting for blood glucose, symptom scores were lower in the elderly and higher in subjects with higher diabetes knowledge scores, microvascular complications, and higher entry hemoglobin A1c. Multiple linear regression showed that the latter three factors were independently predictive of higher symptoms. CONCLUSIONS: Conventional clinical data may be useful in identifying patients with poor hypoglycemia perception. Patients with better long- and short-term glycemic control are at higher risk and may benefit from instruction on all aspects of hypoglycemia.

Aged↗