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Supplemental Material for Yarning about pain: Evaluating communication training for health professionals at persistent pain services in Queensland, Australia by Christina M Bernardes, Stuart Ekberg, Stephen Birch, Andrew Claus, Matthew Bryant, Renata Meuter, Jermaine Isua, Paul Gray, Joseph P Kluver, Eva Malacova, Corey Jones, Kushla Houkamau, Marayah Taylor, Ivan Lin and Gregory Pratt in British Journal of Pain

Medication nonadherence and suboptimal glycemia are common among adults with T2D, particularly minorities and people with low SES. Text messaging is used ubiquitously without disparities. REACH (Rapid Education/Encouragement And Communications for Health) is a theory-based text messaging intervention that iteratively personalizes content to participants’ diabetes medicines and barriers to adherence. All participants have completed 6-month follow-up of a 15-month pragmatic RCT evaluating REACH. Adults (N=512) with T2D were recruited from community health centers and medical center primary care clinics. All participants received educational newsletters, completed A1c tests (venipuncture or mail-in kit) and surveys every 3 months; those assigned to REACH received daily texts. Surveys included a barriers assessment and the Summary of Diabetes Self-Care Activities medications subscale. Regression models examined change in barriers, adherence, and A1c (adjusted for test type) relative to controls. Participants were predominantly non-white (53%) and low SES (56% annual incomes REACH engaged a diverse and high-risk group with daily texts, reduced barriers to adherence, improved adherence, and substantively improved A1c among patients with elevated glycemia at baseline. Disclosure L.S. Mayberry: None. L.A. Nelson: None. R.A. Greevy: None. K. Wallston: None. S. Kripalani: None. C.Y. Osborn: Employee; Self; One Drop. E.M. Bergner: None. L. LeStourgeon: None. S.E. Williamson: None. A.J. Spieker: None. C. Gentry: None. A.W. Brown: None. B.P. Gregory: None. S. Acuff: None. T. Elasy: None. Funding National Institutes of Health (R01DK100694)

Background: Women diagnosed with gestational diabetes mellitus (GDM) substantially modify their diets during pregnancy to control hyperglycemia. These changes could also affect maternal weight management. Materials and Methods: From July 2014 to December 2015 we enrolled women with and without GDM in a prospective cohort study to compare their mean rates of (1) weight gain before GDM screening, (2) weight gain after GDM screening, and (3) postpartum weight loss. All GDM-affected women were referred to Medical Nutrition Therapy and asked to self-monitor blood glucose until delivery. Rate comparisons were conducted separately for each interval using weighted t-tests and inverse probability of treatment weighting (IPTW) to account for age and prepregnancy body mass index (BMI). Linear regression models were developed to characterize the association of GDM status and rate of weight change. Results: The study included 40 women with GDM and 49 women without GDM. The IPTW analysis found that (1) women with and without GDM had similar mean rates of gestational weight gain before GDM screening (0.41 ± 0.26 kg/week vs. 0.45 ± 0.35 kg/week, respectively, p = 0.86), (2) women with GDM gained weight at a significantly lower mean rate than women without GDM following GDM screening (0.30 ± 0.28 kg/week vs. 0.53 ± 0.28 kg/week, respectively, p = 0.001), and (3) women with and without GDM had similar mean rates of postpartum weight loss (−1.37 ± 0.58 kg/week vs. −1.28 ± 0.46 kg/week, respectively, p = 0.73). The linear regression model (adjusted for age and prepregnancy BMI) demonstrated that women with GDM gained 0.19 kg/week less than women without GDM (p = 0.004) during pregnancy after GDM screening. Conclusions: In the postpartum period, women with GDM lose weight at similar rates to women without GDM despite gaining weight at significantly lower rates following GDM screening. Diagnosis and treatment of GDM may improve maternal weight management, but this benefit is limited to late pregnancy.

To compare the effectiveness of different approaches to nutrition education in diabetes self-management education and support (DSME/S).We randomized 150 adults with type 2 diabetes to either certified diabetes educator (CDE)-delivered DSME/S with carbohydrate gram counting or the modified plate method versus general health education. The primary outcome was change in HbA1C over 6 months.At 6 months, HbA1C improved within the plate method [-0.83% (-1.29, -0.33), P0.001] and carbohydrate counting [-0.63% (-1.03, -0.18), P=0.04] groups but not the control group [P=0.34]. Change in HbA1C from baseline between the control and intervention groups was not significant at 6 months (carbohydrate counting, P=0.36; modified plate method, P=0.08). In a pre-specified subgroup analysis of patients with a baseline HbA1C 7-10%, change in HbA1C from baseline improved in the carbohydrate counting [-0.86% (-1.47, -0.26), P=0.006] and plate method groups [-0.76% (-1.33, -0.19), P=0.01] compared to controls.CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10%.Both carbohydrate counting and the modified plate method improve glycemic control as part of DSME/S.

Purpose Patients with low literacy, low numeracy, and/or linguistic needs can experience challenges understanding diabetes information and applying concepts to their self-management. The authors designed a toolkit of education materials that are sensitive to patients’ literacy and numeracy levels, language preferences, and cultural norms and that encourage shared goal setting to improve diabetes self-management and health outcomes. The Partnership to Improve Diabetes Education (PRIDE) toolkit was developed to facilitate diabetes self-management education and support. Methods The PRIDE toolkit includes a comprehensive set of 30 interactive education modules in English and Spanish to support diabetes self-management activities. The toolkit builds upon the authors’ previously validated Diabetes Literacy and Numeracy Education Toolkit (DLNET) by adding a focus on shared goal setting, addressing the needs of Spanish-speaking patients, and including a broader range of diabetes management topics. Each PRIDE module was evaluated using the Suitability Assessment of Materials (SAM) instrument to determine the material’s cultural appropriateness and its sensitivity to the needs of patients with low literacy and low numeracy. Reading grade level was also assessed using the Automated Readability Index (ARI), Coleman-Liau, Flesch-Kincaid, Fry, and SMOG formulas. Conclusions The average reading grade level of the materials was 5.3 (SD 1.0), with a mean SAM of 91.2 (SD 5.4). All of the 30 modules received a “superior” score (SAM >70%) when evaluated by 2 independent raters. The PRIDE toolkit modules can be used by all members of a multidisciplinary team to assist patients with low literacy and low numeracy in managing their diabetes.

OBJECTIVE Diabetic patients with lower literacy or numeracy skills are at greater risk for poor diabetes outcomes. This study evaluated the impact of providing literacy- and numeracy-sensitive diabetes care within an enhanced diabetes care program on A1C and other diabetes outcomes. RESEARCH DESIGN AND METHODS In two randomized controlled trials, we enrolled 198 adult diabetic patients with most recent A1C ≥7.0%, referred for participation in an enhanced diabetes care program. For 3 months, control patients received care from existing enhanced diabetes care programs, whereas intervention patients received enhanced programs that also addressed literacy and numeracy at each institution. Intervention providers received health communication training and used the interactive Diabetes Literacy and Numeracy Education Toolkit with patients. A1C was measured at 3 and 6 months follow-up. Secondary outcomes included self-efficacy, self-management behaviors, and treatment satisfaction. RESULTS At 3 months, both intervention and control patients had significant improvements in A1C from baseline (intervention −1.50 [95% CI −1.80 to −1.02]; control −0.80 [−1.10 to −0.30]). In adjusted analysis, there was greater improvement in A1C in the intervention group than in the control group (P = 0.03). At 6 months, there were no differences in A1C between intervention and control groups. Self-efficacy improved from baseline for both groups. No significant differences were found for self-management behaviors or satisfaction. CONCLUSIONS A literacy- and numeracy-focused diabetes care program modestly improved self-efficacy and glycemic control compared with standard enhanced diabetes care, but the difference attenuated after conclusion of the intervention.

Portion-size estimation is an important component of weight management. Literacy and numeracy skills may be important for accurate portion-size estimation. It was hypothesized that low literacy and numeracy would be associated with decreased accuracy in portion estimation.A cross-sectional study of primary care patients was performed from July 2006 to August 2007; analyses were performed from January 2008 to October 2008. Literacy and numeracy were assessed with validated measures (the Rapid Estimate of Adult Literacy in Medicine and the Wide Range Achievement Test, third edition). For three solid-food items and one liquid item, participants were asked to serve both a single serving and a specified weight or volume amount representing a single serving. Portion-size estimation was considered accurate if it fell within +/-25% of a single standard serving.Of 164 participants, 71% were women, 64% were white, and mean (SD) BMI was 30.6 (8.3) kg/m(2). While 91% reported completing high school, 24% had9th-grade literacy skills and 67% had9th-grade numeracy skills. When all items were combined, 65% of participants were accurate when asked to serve a single serving, and 62% were accurate when asked to serve a specified amount. In unadjusted analyses, both literacy and numeracy were associated with inaccurate estimation. In multivariate analyses, only lower literacy was associated with inaccuracy in serving a single serving (OR=2.54; 95% CI=1.11, 5.81).In this study, many participants had poor portion-size estimation skills. Lower literacy skills were associated with less accuracy when participants were asked to serve a single serving. Opportunities may exist to improve portion-size estimation by addressing literacy.

Purpose Diabetes self-management education is an important component of comprehensive diabetes care. Patients with low health literacy and numeracy may have difficulty translating information from traditional diabetes educational programs and materials into effective self-care. Methods To address this potential barrier to successful diabetes teaching and counseling, the authors developed the Diabetes Literacy and Numeracy Education Toolkit (DLNET). Conclusion The DLNET is composed of 24 interactive modules covering standard diabetes care topics that can be customized to individual patient needs and used by all members of the multidisciplinary diabetes care team. The material's content and formatting aims to improve the ease of use for diabetes patients with low literacy and numeracy by adhering to a lower text reading level, using illustrations for key concepts, and color-coding and other accommodations to guide patients through instructions for self-care. Individual sections of the DLNET may be provided to patients for initial teaching, as well as for reinforcement. Although designed for lower literacy and numeracy skills, the DLNET provides unique materials to facilitate diabetes education for all patients.

Nurses increasingly use telephonic assessment and counseling to manage clients with a variety of chronic illnesses. This article describes a study designed to assess a group of telephonic nurse disease managers' teaching and adherence promotion skills during actual patient interactions. Nurse care managers showed improvements after training in four main counseling skills categories, with a decrease in time spent.

Objective: The primary treatment for adults with risk factors for metabolic syndrome is lifestyle change, though adoption of traditional lifestyle programs is often limited. This pilot study tested the feasibility of conducting a randomized clinical trial comparing a novel targeted yoga program coupled to lifestyle education versus lifestyle education alone among adults with metabolic syndrome risk factors. Design and methods: Patients from primary care clinic were pre-screened electronically and further screened for metabolic syndrome. Consented participants were randomized to either a 12-week yoga program with lifestyle education or lifestyle education alone. Participants in the yoga arm received weekly 30 to 45 min of face-to-face yoga instruction, followed by 30 to 45 min of lifestyle education, and written instructions for home yoga practice and lifestyle changes. The lifestyle education was based on (EDU) the Group Lifestyle Balance Program that is adapted from the Diabetes Prevention Program. Participants in EDU only group received a weekly standardized curriculum matched in attention and time to the yoga with EDU arm. The primary outcome was to assess the feasibility of conducting a randomized trial by assessing recruitment rate and adherence to the protocol. Secondly, we aimed to collect preliminary data on changes in cardiometabolic factors including insulin resistance (IR) as measured by Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), blood pressure, fasting lipids, body weight and composition, habitual physical activity, and dietary intake from baseline to 12-week intervention. Results: We identified 238 adults at high risk for metabolic syndrome medical records review utilizing an electronic recruitment tool. Among eligible individuals, 67 (28%) were enrolled and 56 (84%) completed the 12-week assessment. The median attendance was 8 of 12 sessions for the yoga with EDU and 9 of 12 sessions for the EDU arm. Self-reported median frequency of home practice was 2.8 (IQR 1.4) times per week among the yoga with EDU group and 3.3 (IQR 1.1) times per week among the EDU group. Participants in the yoga with EDU arm versus EDU alone demonstrated a non-significant decrease in HOMA-IR (-0.21 (S.D. 0.99) versus 0.02 (S.D. 0.74), p=0.29). Both groups had similar changes in blood pressure, lipids, weight, body composition, energy intake, and physical activity from baseline to 12 weeks. Conclusions: It is feasible to implement yoga combined with EDU and conduct a prospective trial to assess effectiveness on cardiometabolic risk reduction in adults with metabolic syndrome.

Background Comprehension of food labels can be important for patients, including those with chronic illness, to help follow dietary recommendations. Patient comprehension of food labels was examined, along with the relationship of comprehension to their underlying literacy and numeracy skills. Methods From June 2004 to April 2005, a cross-sectional study of 200 primary care patients was performed. A 24-item measure of food label comprehension was administered. Literacy was measured with the Rapid Estimate of Adult Literacy in Medicine (REALM), and numeracy with the Wide Range Achievement Test, third edition (WRAT-3). Results Most patients (89%) reported using food labels. While 75% of patients reported at least a high school education and 77% had 9th-grade literacy skills, only 37% had 9th-grade math skills. On average, patients answered 69% (standard deviation, 21%) of the food-label questions correctly. Common reasons for incorrect responses included misapplication of the serving size, confusion due to extraneous material on the food label, and incorrect calculations. For example, only 37% of patients could calculate the number of carbohydrates consumed from a 20-ounce bottle of soda that contained 2.5 servings. Higher comprehension of food labels was significantly correlated (all p values were less than 0.001) with higher income (rho=0.39), education (rho=0.49), literacy (rho=0.52), and numeracy (rho=0.67). Conclusions Patients demonstrated deficits in understanding nutrition labels. Poor label comprehension was highly correlated with low-level literacy and numeracy skills, but even patients with higher literacy could have difficulties interpreting labels. Providers need to consider patients' literacy and numeracy when providing dietary recommendations. Opportunities may exist for the U.S. Food and Drug Administration to promote changes to make food labels more comprehensible.

To compare practice patterns of the American College of Obstetrician and Gynecologists (ACOG) Fellows for the diagnosis and treatment of gestational diabetes mellitus (GDM) and type 1 diabetes mellitus with current ACOG recommendations and prior published series.We sent a questionnaire to 1,398 practicing ACOG Fellows and Junior Fellows, 398 of whom comprise the Collaborative Ambulatory Research Network. Responses were evaluated by age and sex to assess differences in practice.Younger physicians were more likely to treat pregnant patients. Ninety-six percent of obstetricians routinely screen for GDM, nearly all by using a 50-g glucose 1-hour oral test. Nearly 60% of respondents establish the diagnosis of GDM using the National Diabetes Data Group criteria. In addition to medical nutrition therapy, almost 75% of respondents recommend exercise for patients with GDM. Approximately 60% of respondents reported that all of their patients with GDM self-monitor their blood glucose. When medical nutrition therapy is ineffective for their patients with GDM, 82% of respondents initially prescribe insulin, whereas 13% begin with glyburide. Nearly 75% of respondents routinely perform a postpartum evaluation of glucose tolerance in the patient with GDM. Most obstetricians manage the glucose control of their patients with type 1 diabetes mellitus themselves.Practicing obstetrician-gynecologists have incorporated recent recommendations into their practice patterns for both GDM and type 1 diabetes mellitus, including patients' self-monitoring of blood glucose, exercise, and postpartum testing in GDM.III

Self-efficacy is often studied as a predictor of professional practice behaviors or as an outcome of clinical training, using brief scales with little validation. This study examines the utility of a brief self-efficacy scale in the evaluation of a clinical training program. Subjects were 119 registered dietitians who participated in diabetes training. Hypothesized relationships between self-efficacy ratings and indices of skill mastery, participation in training, and subsequent practice change were examined. Self-efficacy ratings after training correlated significantly with relevant prior experience (r = .4 and .29, p < .01) but not total experience and with knowledge post-test score (r = .21, p < .02). Self-efficacy for all 12 program objectives increased significantly after training. Post-training self-efficacy for two program objectives correlated significantly with self-reported successful practice changes related to those objectives (r = .4, p < .04 and r = .51, p < .01). The data suggest that brief self-efficacy assessments can contribute meaningfully to clinical training program evaluation.

Recent changes in management and medical nutrition therapy for diabetes mellitus. have produced a need to retrain many practicing dietitians. To meet this need, a multidisciplinary group experienced in medical nutrition therapy and educational methods used a formal needs-assessment process to design a new training program. Sugar is Not a Poison (SNAP): The Dietitian's New Role in Diabetes Management is a 21/2-day program that uses written text, didactic presentation, and exercises that simulate patient encounters to accomplish 12 learning objectives. Program evaluations show high levels of participant satisfaction. Mean (±standard deviation) scores on pre- and posttests of knowledge and problem solving were 69±13% and 86±9%, respectively ( P J Am Diet Assoc. 2000; 100:225-228.

A lthough benefits of medical nutrition therapy (MNT) in the management of diabetes have been well established, lack of time to address nutrition or the many other diabetes self-management tasks is an obstacle for most physicians. This article offers some simple strategies for physicians to use to address nutrition with both type 1 and type 2 diabetes patients before they are able to see a registered dietitian (RD). Weight loss is not always enough to bring blood glucose values into target range. There are several potential reasons: 1. If loss of β-cell function is severe, weight loss is unlikely to compensate. 2. Weight loss does not address postprandial blood glucose excursions. 3. Many patients have failed at weight loss or the maintenance of weight loss and need success to build confidence. Although weight loss is important for a variety of reasons, asking patients who have made multiple unsuccessful attempts at long-term weight loss to again attempt dieting can be frustrating for both patients and physicians. Patients with a poor weight loss track record may tune out additional weight loss advice. Changing the focus from losing weight to controlling carbohydrate intake may allow this type of patient to gain success and build confidence. Identifying and reducing excessive carbohydrate intake may reduce postprandial glucose excursions. High postprandial blood glucose has been shown to be an independent risk factor for cardiovascular disease; targeting it has been shown to improve blood glucose control. To assist patients in this goal: 1. Help patients identify large servings of juice or …

Diabetes education to improve patient self-management is an important component of comprehensive diabetes care. Patients with low health literacy and numeracy may have difficulty translating information from traditional diabetes educational programs and materials into effective self-care. To address this potential barrier to successful diabetes teaching and counseling, we describe the development of the Diabetes Literacy and Numeracy Education Toolkit (DLNET) and opportunities for its use in clinical practice. The DLNET is composed of 24 interactive modules covering standard diabetes care topics that can be customized to individual patient needs and utilized by all members of the multidisciplinary diabetes care team. The material’s content and formatting aims to improve the ease of use for diabetes patients with low literacy and numeracy by adhering to a lower text reading level, using illustrations for key concepts, and color-coding and other accommodations to guide patients through instructions for self-care. Individual sections of the DLNET may be provided to patients for initial teaching, as well as for reinforcement. While designed for lower literacy and numeracy skills, the DLNET provides unique materials to facilitate diabetes education for all patients.

Eukaryotic proteasomes have been reported to cleave only once within polyglutamine tracts and then only after the N-terminal glutamine (Venkatraman, P., Wetzel, R., Tanaka, M., Nukina, N., and Goldberg, A. L. (2004) Mol. Cell 14, 95–104). We have obtained results that directly conflict with that report. In the presence of the proteasome activator PA28γ(K188E) human red cell proteasomes progressively degraded fluorescein-GGQ10RR or fluorescein-HPHQ10RR into small fragments as shown by size exclusion chromatography and mass spectrometry. MALDI-TOF mass spectrometry revealed that proteolytic products arose from cleavage after every glutamine in fluorescein-HPHQ10RR, and mass accuracy rules out deamidation of glutamine to glutamic acid as an explanation for peptide degradation. Moreover, degradation cannot be attributed to a contaminating protease because peptide hydrolysis was completely blocked by the proteasome-specific inhibitors, lactacystin and epoxomicin. We conclude that proteasomes cleave repetitively anywhere within a stretch of ten glutamine residues. Thus our results cast doubt on the idea that mammalian proteasomes cannot degrade glutamine-expanded regions within pathogenic polyQ-expanded proteins, such as Huntingtin.

Purpose The purpose of this feasibility study was to examine primary care pediatricians and a diabetes specialty team sharing the care of children with type 1 diabetes in a structured network. Methods A diabetes specialty team and 3 pediatric practice groups participated in training and shared care of patients with type 1 diabetes. The diabetes team-consisting of 1 pediatric endocrinologist, 2 nurses in advanced practice, and 1 master's-prepared registered dietitian-initiated therapy and self-management training for families; pediatricians implemented maintenance therapy. Role definitions, specially developed records, and a communication framework guided the interaction of providers. Satisfaction of families and pediatricians was assessed by questionnaire. The A1C level was used to assess patients' metabolic control. Results Twenty-nine patients accepted pediatrician referral, 25 kept initial training sessions, and 20 completed at least 1 year in the network. All 24 invited pediatricians participated, and 17 enrolled patients. All families who completed satisfaction surveys were highly satisfied with the network. Nineteen pediatricians completed end-of-study questions and were also highly positive about sharing care with the specialty team. The mean A1C value was near target levels or better the first year, and it rose during the second year. Conclusions The study supports the feasibility of integrating general pediatrician and diabetes specialty services for children with type 1 diabetes. Larger studies are justified to assess the efficacy and effectiveness of shared care.

women with pregestational diabetes Etoi Garrison, Cornelia Graves, Rebecca Gregory, Russell Rothman, James Slaughter, Sarah Fletcher, Kelly A. Bennett Vanderbilt University School of Medicine, Obstetrics and Gynecology, Nashville, TN, St. Thomas Health-Baptist Hospital, Obstetrics and Gynecology, Nashville, TN, Vanderbilt University Medical Center, Eskind Diabetes Center, Nashville, TN, Vanderbilt University School of Medicine, Medicine, Nashville, TN, Vanderbilt University School of Medicine, Biostatistics, Nashville, TN, Vanderbilt University School of Medicine, Obstetrics and Gynecology, Nashville, TN OBJECTIVE: Numeracy is defined as the ability to use numbers and math in daily life. Diabetes-related numeracy skills may be used to perform diabetes-related tasks for self-management of Type 1 and Type 2 diabetes. Inadequate health literacy and poor diabetes-related numeracy have been found to be independently associated with poor glycemic control among nonpregnant adult diabetics. This association in diabetes during pregnancy has not been well studied. We investigated this association in a defined pregnant diabetic population. STUDY DESIGN: Subjects were prospectively enrolled and administered validated measures of literacy (REALM), diabetes-related numeracy (DNT), and perceived self-efficacy (PDSMS). Glucose meter readings and A1C data were collected at baseline enrollment and prior to delivery. Univariate analyses were conducted. RESULTS: Fifty-eight subjects were recruited, 52% (n 30) with Type 1 and 48 % (n 28) with Type 2 diabetes. Subjects were high school educated, but 8% had less than 9th grade literacy skills. Mean baseline A1C was 7.0%, mean DNT score was 84 out of 100. Thirty-three percent could not use a food label to determine caloric content based upon serving size. Seventy-one percent of the Type 2 diabetics and 41 % of the Type 1 diabetics were unable to use a nutrition label to calculate carbohydrate grams based upon serving size. Eighteen percent of the Type 2 diabetics could not use numerical hierarchy to determine which glucose values were above or below a normal reference range. Health literacy and DNT scores were negatively and significantly associated with HgBA1C (r2 0.08 p 0.04; r2 0.11, p 0.01), respectively. Every 14% increase in DNT score was associated with a 0.35 (Type I) and 0.52 (Type II) decrease in HgBA1C (p 0.04). CONCLUSION: In this defined group, health literacy and numeracy-dependent diabetes self-management skills were significantly associated with better glycemic control. This data may be useful in the development of targeted diabetes education tools in pregnancy. 252 TNF alpha has a direct inhibitory effect on Ca2 responses necessary for eNOS activation in primary HUVEC Heather Bankowski, Fu Xian Yi, Derek Boeldt, Dinesh Shah, Ian Bird University of Wisconsin, Obstetrics and Gynecology, Maternal Fetal Medicine, Madison, WI, University of Wisconsin, Obstetrics and Gynecology, Madison, WI, University of WI School of Medicine and Public Health, Obstetrics and Gynecology, Madison, WI, University of WI School of Medicine and Public Health, Obstetrics and Gynecology, Maternal Fetal Medicine, Madison, WI, University of WI School of Medicine and Public Health, Obstetrics and Gynecology & Pediatrics, Madison, WI OBJECTIVE: Evidence suggests that the pathologic metabolic state of diabetes mellitus(DM)results in oxidative stress. Tumor necrosis factor alpha (TNF ) has been shown to induce intracellular reactive oxygen species formation and is proposed to be a significant perpetrator of insulin resistance in gestational diabetes mellitus (GDM). Previously we have shown in DM HUVEC in vivo ROS damage to eNOS protein. Even in GDM patients, there is a overall decrease in NO production consistent with ROS damage of functional eNOS protein, despite maintenance of eNOS protein levels. It is known that sustained Ca2 elevation is also required for eNOS activity. Could TNF also inhibit NO production at the level of Ca2 signaling? Hypothesis: The decrease in agonist stimulated NO production due to TNF stimulated ROS production may not only occur through damage to eNOS protein in DM HUVEC but may also involve direct impairment of Ca2 signaling mechanisms necessary for eNOS activation. STUDY DESIGN: HUVEC cells from a combined pool of control patients were prepared at a density of 95%. HUVEC underwent acute (30 minutes)and chronic (16 hours) treatments with 50, 10 or 1 ng/ml TNF prior to imaging using Fura-2 to detect Ca2 in real time in response to 30 minute stimulation with ATP (100 uM). RESULTS: There were statistically significant reductions (P 0.05) in burst numbers in cells in the acute and chronic TNF treatment groups (Fig. 1). The decrease in Ca2 bursts was dose dependent in each case. In addition to the damaged eNOS protein itself, there is an acute, direct effect of TNF to directly inhibit eNOS activation by also impairing sustained Ca2 signaling in the form of repetitive bursts. These in vitro findings compliment our prior observations on in vivo ROS damage to eNOS in DM HUVEC. CONCLUSION: Ultimately, such improved understanding of the inhibitory role of TNF and other inflammatory cytokines will lead to a therapeutic strategy to reduce oxidative stress and development of macro and micro-vascular complications in pregnancies complicated by DM. www.AJOG.org Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging Poster Session II

Certain questions often arise regarding carbohydrate counting, such as: Why use carbohydrate counting ? Where does one start? How much carbolrydrate is prescribed? How does one balance the diet? How is carbohydrate counting taught to patients? Which patients are the best candidates for carbohydrate counting? This article provides possible answers to these questions based on clinical experience at the Vanderbilt University Medical Center Diabetes Research and Training Center, and the Diabetes Control and Complications Trial.

This paper describes a nutrition education experiment in which traditional direct instruction was compared with a problem-solving method called anchored instruction (AI). Participants were 69 children ages 9 to 15 years, with insulin-dependent diabetes mellitus (IDDM), who attended a diabetes camp. Following pretesting, campers were assigned to AI or direct instruction control classes. Posttests involved evaluating diabetes knowledge, personal meal plan knowledge, ability to choose an appropriate meal from a buffet line, and ability to pack appropriate meals for an overnight campout. AI and direct instruction both produced significant knowledge gains in this study. However, because the scores for the two groups did not differ, this study was unsuccessful in replicating results of other studies or extending the findings to selected measures of actual behavior.

The influence of a patient's quantitative skills (numeracy) on the management of diabetes is only partially understood.To examine the association between diabetes-related numeracy and glycemic control and other diabetes measurements.Cross-sectional survey.2 primary care and 2 diabetes clinics at 3 medical centers.398 adult patients with type 1 or type 2 diabetes mellitus enrolled between March 2004 and November 2005.Health literacy, general numeracy, and diabetes-related numeracy assessed by using the Rapid Estimate of Adult Literacy in Medicine; the Wide Range Achievement Test, 3rd edition; and the Diabetes Numeracy Test (DNT), respectively. The primary outcome was most recent level of hemoglobin A1c. Additional measurements were diabetes knowledge, perceived self-efficacy of diabetes self-management, and self-management behaviors.The median DNT score was 65% (interquartile range, 42% to 81%). Common errors included misinterpreting glucose meter readings and miscalculating carbohydrate intake and medication dosages. Lower DNT scores were associated with older age, nonwhite race, fewer years of education, lower reported income, lower literacy and general numeracy skills, lower perceived self-efficacy, and selected self-management behaviors. Patients scoring in the lowest DNT quartile (score42%) had a median hemoglobin A1c level of 7.6% (interquartile range, 6.5% to 9.0%) compared with 7.1% (interquartile range, 6.3% to 8.1%) in those scoring in the highest quartile (P = 0.119 for trend). A regression analysis adjusted for age, sex, race, income, and other factors found a modest association between DNT score and hemoglobin A1c level.Causality cannot be determined in this cross-sectional study, especially with its risk for unmeasured confounding variables.Poor numeracy skills were common in patients with diabetes. Low diabetes-related numeracy skills were associated with worse perceived self-efficacy, fewer self-management behaviors, and possibly poorer glycemic control.

Background Low literacy and numeracy skills are common. Adequate numeracy skills are crucial in the management of diabetes. Diabetes patients use numeracy skills to interpret glucose meters, administer medications, follow dietary guidelines and other tasks. Existing literacy scales may not be adequate to assess numeracy skills. This paper describes the development and psychometric properties of the Diabetes Numeracy Test (DNT), the first scale to specifically measure numeracy skills used in diabetes. Methods The items of the DNT were developed by an expert panel and refined using cognitive response interviews with potential respondents. The final version of the DNT (43 items) and other relevant measures were administered to a convenience sample of 398 patients with diabetes. Internal reliability was determined by the Kuder-Richardson coefficient (KR-20). An a priori hypothetical model was developed to determine construct validity. A shortened 15-item version, the DNT15, was created through split sample analysis. Results The DNT had excellent internal reliability (KR-20 = 0.95). The DNT was significantly correlated (p < 0.05) with education, income, literacy and math skills, and diabetes knowledge, supporting excellent construct validity. The mean score on the DNT was 61% and took an average of 33 minutes to complete. The DNT15 also had good internal reliability (KR-20 = 0.90 and 0.89). In split sample analysis, correlations of the DNT-15 with the full DNT in both sub-samples was high (rho = 0.96 and 0.97, respectively). Conclusion The DNT is a reliable and valid measure of diabetes related numeracy skills. An equally adequate but more time-efficient version of the DNT, the DNT15, can be used for research and clinical purposes to evaluate diabetes related numeracy.

Background Diabetes is a common disease with self-management a key aspect of care. Large prospective trials have shown that maintaining glycated hemoglobin less than 7% greatly reduces complications but translating this level of control into everyday clinical practice can be difficult. Intensive improvement programs are successful in attaining control in patients with type 2 diabetes, however, many patients experience glycemic relapse once returned to routine care. This early relapse is, in part, due to decreased adherence in self-management behaviors. Objective This paper describes the design of the Glycemic Relapse Prevention study. The purpose of this study is to determine the optimal frequency of maintenance intervention needed to prevent glycemic relapse. The primary endpoint is glycemic relapse, which is defined as glycated hemoglobin greater than 8% and an increase of 1% from baseline. Methods The intervention consists of telephonic contact by a nurse practitioner with a referral to a dietitian if indicated. This intervention was designed to provide early identification of self-care problems, understanding the rationale behind the self-care lapse and problem solve to find a negotiated solution. A total of 164 patients were randomized to routine care (least intensive), routine care with phone contact every three months (moderate intensity) or routine care with phone contact every month (most intensive). Conclusion The baseline patient characteristics are similar across the treatment arms. Intervention fidelity analysis showed excellent reproducibility. This study will provide insight into the important but poorly understood area of glycemic relapse prevention.