Diabetes mellitus is a leading cause of morbidity and death in the United States. Type 2 diabetes mellitus accounts for the majority of affected persons (90% to 95%) and affects older adults, particularly those older than 50 years of age. It affects an estimated 16 million Americans, 11 million of whom have both diabetes and hypertension. Most adverse diabetes outcomes are a result of vascular complications. These complications are generally classified as microvascular, such as retinopathy, nephropathy, and neuropathy (although neuropathy may not be entirely a microvascular disease), or macrovascular, such as coronary artery disease, cerebrovascular disease, and peripheral vascular disease.

In order to prevent, or diminish the progression of, microvascular and macrovascular complications, recommended diabetes management necessarily encompasses both metabolic control and cardiovascular risk factor control. The need for good glycemic control is supported by the Diabetes Control and Complications Trial in type 1 diabetes mellitus and, more recently, the United Kingdom Prospective Diabetes Study (UKPDS) in type 2 diabetes mellitus. In these studies, tight blood sugar control reduced microvascular complications, such as nephropathy and retinopathy, but had little effect on macrovascular outcomes. Up to 80% of patients with type 2 diabetes mellitus will develop or die of macrovascular disease, underscoring the importance of preventing macrovascular complications.

In an effort to provide internists and other primary care physicians with effective management strategies for diabetes care, the American College of Physicians decided to develop guidelines on the management of hypertension in people with type 2 diabetes mellitus. The target audience for this guideline is all clinicians who provide care to patients with type 2 diabetes. The target patient population is all persons with type 2 diabetes who have hypertension, defined as systolic blood pressure of at least 140 mm Hg or diastolic blood pressure of at least 90 mm Hg. This target patient population includes those who already have some form of microvascular complication and, of particular importance, premenopausal women with diabetes. We will attempt to answer the following questions: 1) What are the benefits of tight blood pressure control in type 2 diabetes? 2) What should the target levels of systolic blood pressure and diastolic blood pressure be for patients with type 2 diabetes? and 3) Are certain antihypertensive agents more effective or beneficial in patients with diabetes?

When analyzing benefit or effectiveness for this review, we included only studies that measured clinical end points. The four major classes of clinical end points were all-cause mortality, cardiovascular mortality, cardiovascular events (myocardial infarction, stroke, or congestive heart failure), and microvascular complications (photocoagulation, nephropathy, neuropathy, or amputation).

The review was divided into two categories. The first included studies that evaluated the effects of blood pressure control if the comparison examined an antihypertensive drug versus placebo or the effects of different target blood pressure levels. The second category evaluated the effect of different classes of drugs. A discussion of this evidence follows.

Context Low-carbohydrate diets have been popularized without detailed evidence of their efficacy or safety. The literature has no clear consensus as to what amount of carbohydrates per day constitutes a low-carbohydrate diet.

Objective To evaluate changes in weight, serum lipids, fasting serum glucose, and fasting serum insulin levels, and blood pressure among adults using low-carbohydrate diets in the outpatient setting.

Data Sources We performed MEDLINE and bibliographic searches for English-language studies published between January 1, 1966, and February 15, 2003, with key words such as low carbohydrate, ketogenic, and diet.

Study Selection We included articles describing adult, outpatient recipients of low-carbohydrate diets of 4 days or more in duration and 500 kcal/d or more, and which reported both carbohydrate content and total calories consumed. Literature searches identified 2609 potentially relevant articles of low-carbohydrate diets. We included 107 articles describing 94 dietary interventions reporting data for 3268 participants; 663 participants received diets of 60 g/d or less of carbohydrates—of whom only 71 received 20 g/d or less of carbohydrates. Study variables (eg, number of participants, design of dietary evaluation), participant variables (eg, age, sex, baseline weight, fasting serum glucose level), diet variables (eg, carbohydrate content, caloric content, duration) were abstracted from each study.

Data Extraction Two authors independently reviewed articles meeting inclusion criteria and abstracted data onto pretested abstraction forms.

Data Synthesis The included studies were highly heterogeneous with respect to design, carbohydrate content (range, 0-901 g/d), total caloric content (range, 525-4629 kcal/d), diet duration (range, 4-365 days), and participant characteristics (eg, baseline weight range, 57-217 kg). No study evaluated diets of 60 g/d or less of carbohydrates in participants with a mean age older than 53.1 years. Only 5 studies (nonrandomized and no comparison groups) evaluated these diets for more than 90 days. Among obese patients, weight loss was associated with longer diet duration (P = .002), restriction of calorie intake (P = .03), but not with reduced carbohydrate content (P = .90). Low-carbohydrate diets had no significant adverse effect on serum lipid, fasting serum glucose, and fasting serum insulin levels, or blood pressure.

Conclusions There is insufficient evidence to make recommendations for or against the use of low-carbohydrate diets, particularly among participants older than age 50 years, for use longer than 90 days, or for diets of 20 g/d or less of carbohydrates. Among the published studies, participant weight loss while using low-carbohydrate diets was principally associated with decreased caloric intake and increased diet duration but not with reduced carbohydrate content.

OBJECTIVE: The prevalence of type 2 diabetes, especially in developing countries, has grown over the past decades. We performed a controlled clinical study to determine whether a community-based, group-centered public health intervention addressing nutrition and exercise can ameliorate glycemic control and associated cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica.

RESEARCH DESIGN AND METHODS: A total of 75 adults with type 2 diabetes, mean age 59 years, were randomly assigned to the intervention group or the control group. All participants received basic diabetes education. The subjects in the intervention group participated in 11 weekly nutrition classes (90 min each session). Subjects for whom exercise was deemed safe also participated in triweekly walking groups (60 min each session). Glycosylated hemoglobin, fasting plasma glucose, total cholesterol, triglycerides, HDL and LDL cholesterol, height, weight, BMI, and blood pressure were measured at baseline and the end of the study (after 12 weeks).

RESULTS: The intervention group lost 1.0 +/- 2.2 kg compared with a weight gain in the control group of 0.4 +/- 2.3 kg (P = 0.028). Fasting plasma glucose decreased 19 +/- 55 mg/dl in the intervention group and increased 16 +/- 78 mg/dl in the control group (P = 0.048). Glycosylated hemoglobin decreased 1.8 +/- 2.3% in the intervention group and 0.4 +/- 2.3% in the control group (P = 0.028).

CONCLUSIONS: Glycemic control of type 2 diabetic patients can be improved through community-based, group-centered public health interventions addressing nutrition and exercise. This pilot study provides an economically feasible model for programs that aim to improve the health status of people with type 2 diabetes.

The Institute of Medicine recently issued a landmark report on medical error. In light of this report, every aspect of health care is subject to new scrutiny regarding patient safety. Informatics technology can support patient safety by correcting problems inherent in older technology; however, new information technology can also contribute to new sources of error. We report here a categorization of possible errors that may arise in deploying a system designed to give guideline-based advice on prescribing drugs, an approach to anticipating these errors in an automated guideline system, and design features to minimize errors and thereby maximize patient safety. Our guideline implementation system, based on the EON architecture, provides a framework for a knowledge base that is sufficiently comprehensive to incorporate safety information, and that is easily reviewed and updated by clinician-experts.

Also published in the Proceedings of the American Medical Informatics Association's 2001 Symposium.

Automated quality assessment of clinician actions and patient outcomes is a central problem in guideline- or standards-based medical care. In this paper we describe a unified model representation and algorithm for evidence-adaptive quality assessment scoring that can: (1) use both complex case-specific guidelines and single-step population-wide performance-indicators as quality measures; (2) score adherence consistently with quantitative population-based medical utilities of the quality measures where available; and (3) give worst-case and best-case scores for variations based on (a) uncertain knowledge of the best practice, (b) guideline customization to an individual patient or particular population, (c) physician practice style variation, or (d) imperfect reliability of the quality measure. Our solution uses fuzzy measure-theoretic scoring to handle the uncertain knowledge about best-practices and the ambiguity from practice variation. We show results of applying our method to retrospective data from a guideline project to improve the quality of hypertension care.

BACKGROUND: Electronically available data, both administrative, such as outpatient encounter diagnostic data, and clinical, such as problem lists, are being used increasingly for outcome and quality assessment, risk adjustment, and clinical reminder systems. OBJECTIVE: To determine the accuracy of outpatient primary care diagnostic information recorded in administrative and clinical files in a Veterans Affairs VISTA (Veterans Health Information Systems and Technology Architecture) database compared with medical chart notes. STUDY DESIGN: Cross-sectional medical chart review of 148 patients attending a general medicine clinic at a university-affiliated Veterans Affairs hospital for 9 diagnoses relevant to the choice of drug therapy for hypertension. PATIENTS AND METHODS: An administrative file of encounter diagnoses, for a 2-year period, and a clinical file of the problem list maintained by the clinician were the sources of electronic diagnoses. We compared these sources with diagnoses abstracted by medical chart review. We estimated the sensitivity and specificity of each electronic data source for detecting medical chart note diagnoses. RESULTS: The sensitivity for 8 of the 9 study diagnoses was greater than 80% in the administrative file and 49% in the clinical problem list. The specificity was good for the administrative file (91% to 100%) and even better for the clinical file (98% to 100%). CONCLUSIONS: Outpatient encounter diagnoses relevant to hypertension recorded as electronic data had high specificity, and some codes had high sensitivity when collected over multiple visits. The administrative file was more sensitive but less specific than the clinical file. Administrative vs clinical files can be selected to minimize either the false-negative or the false-positive designations, respectively, as dictated by the needs of the quality assessment review.

Once again the authors have brought this basic backlist book up to current standards including the newest information available on medication, diet, and exercise. This edition also presents new information about hypertension and the standards recently established for measurement. It is a clear and jargon-free explanation of the role blood pressure plays as a primary indicator of overall health.

The Blood Pressure Book reviews the causes and treatments of high blood pressure and provides guidance on equipment for home monitoring as well as complete and fully updated references throughout the book and the bibliography.

The advice is broken down into a series of small steps that are easy to take. By the end of the book, these small changes should add up to a way of life that will help get blood pressure down (or keep it from going up) and also improve general health. This is an important reference for anyone with high blood pressure in the family, from young adults to seniors.