Biomarkers and undiagnosed disease

Size: px
Start display at page:

Download "Biomarkers and undiagnosed disease"

Transcription

1 Biomarkers and undiagnosed disease Soham Al Snih, MD, Ph.D The University of Texas Medical Branch, Galveston, TX May 29, 2015 Mexico City, Mexico

2 Biomarkers Broad subcategory of medical signs Objective indications of medical state observed from outside the patient Can be measured accurately and reproducibly

3 Biomarkers Many terms are used to describe measurements of disease and treatment: Biological markers Biomarkers Surrogate markers Surrogate endpoints Intermediate endpoints Involvement of a variety of disciplines - clinical trialists, statisticians, regulators, and therapeutic developers

4 Biomarkers Biomarkers Definition Working Group, convened by the National Institutes of Health Director's Initiative on Biomarkers and Surrogate Endpoints Biological marker (biomarker) A characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention

5 Biomarkers Applications in disease detection and monitoring of health status Use as a diagnostic tool for the identification of those patients with a disease or abnormal condition - Elevated blood glucose concentration for the diagnosis of diabetes mellitus Use as a tool for staging of disease - Measurements of carcinoembryonic antigen- 125 for various cancers - Classification of the extent of disease (prostatespecific antigen concentration in blood used to reflect extent of tumor growth and metastasis)

6 Biomarkers Applications in disease detection and monitoring of health status Use as an indicator of disease prognosis - Anatomic measurement of tumor shrinkage of certain cancers Use for prediction and monitoring of clinical response to an intervention - Blood cholesterol concentrations for determination of the risk of heart disease

7 Biomarkers Clinical endpoint A characteristic or variable that reflects how a patient feels, functions, or survives - Quality of life - Physical and cognitive function - Disability

8 Biomarkers Surrogate endpoint A biomarker that is intended to substitute for a clinical endpoint Is expected to predict clinical benefit (or harm or lack of benefit) based on epidemiologic, therapeutic, pathophysiologic, or other scientific evidence

9 Biomarkers Characteristics of an ideal biomarker Safe and easy to measure Cost efficient to follow up Modifiable with treatment Consistent across gender and race/ethnic groups

10 Biomarkers Biomarkers of aging Predict a person s physiological, cognitive, and physical function independent of chronological age Testable and not harmful to the test subjects (blood tests or imaging technique) Work in laboratory animals as well as humans

11 Biomarkers Advantages and Disadvantages Advantages Objective assessment Precision of measurement Reliable; validity can be established Less biased than questionnaires Disease mechanisms often studied Homogeneity of risk or disease Disadvantages Timing is critical Expensive (costs for analyses) Storage (longevity of samples) Laboratory errors Normal range difficult to establish Ethical responsibility

12 Biomarkers Biomarkers of aging under investigation in laboratory and epidemiologic research Biomarker Measured aspect of aging Associated disease if high Interleukin 6 C-reactive protein Inflammation, infection, oxidation Inflammation, infection, oxidation, liver function CVD, cancer, diabetes, sarcopenia, frailty, cognitive decline CVD, cancer, diabetes, sarcopenia, frailty, cognitive decline Aortic calcification Arteriosclerosis Arteriosclerosis Pulse wave velocity Arterial stiffness Hypertension Associated disease if low Liver disease Brain volume Cognitive reserve Dementia Gait speed Muscle function, peripheral and central nervous system function, cardio-pulmonary fitness

13 Biomarkers NIA Biomarkers of disease progression Launch research programs to develop and validate sensitive neuropsychological assessment measures to detect and track the earliest clinical manifestations of Alzheimer s disease

14 Biomarkers Latin America Mexican Health and Aging Study (MHAS) Cost a Rican Longevity and Health Aging Study Health, Well-Being and Aging in Latin America and the Caribbean (SABE) Study SABE Brazil SABE Colombia United States Health and Retirement Study Baltimore Longitudinal Study on Aging Europe English Longitudinal Study of Ageing (ELSA) Survey of Health, Aging and Retirement in Europe (SHARE) The Irish Longitudinal Study on Ageing (TILDA) Asia Korean Longitudinal Study on Ageing Japanese Study of Aging and Retirement (JSTAR) The China Health Aging and Retirement Longitudinal Study

15 Undiagnosed disease Undiagnosed diabetes: Findings from the Mexican Health and Aging Study Use as a diagnostic tool for the identification of those patients with a disease or abnormal condition

16 Undiagnosed disease Global diabetes prevalence International Diabetes Federation, 6 th Edition, 2014

17 Undiagnosed disease NORTH AMERICA AND CARIBBEAN at a glance 38.8 million people have diabetes - 1 in 9 adults Highest prevalence across regions 11.5% Lowest undiagnosed rate 27.1% USD 310 billion expenditure more than all other regions combined International Diabetes Federation, 6 th Edition, 2014

18 Undiagnosed disease SOUTH AND CENTRAL AMERICA at a glance 25 million people have diabetes - 1 in 12 adults 5% of worldwide expenditure USD 28.7 billions International Diabetes Federation, 6 th Edition, 2014

19 Undiagnosed disease Expert Committee on Diagnosis and Classification of Diabetes Mellitus A1C 6.5% The test should be performed in a laboratory using a method that is NGSP* certified and standardized to the DCCT assay OR FPG 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h OR Two-hour PG 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water OR In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200 mg/dl (11.1 mmol/l) * National Glycohemoglobin Standardized Program Diabetes Care 38, Supplement 1, January 2015

20 Undiagnosed disease Prevalence of undiagnosed diabetes in Mexico National Health and Nutrition Survey (ENSANUT) 2006 subsample of 4,687 participants without previous diagnosis of diabetes IFG % Abdominal obesity was the antrhopometric measure strongly associated with undiagnosed diabetes

21 Collection of intravenous and capillary blood tests: hemoglobin, HbA1c, total cholesterol, high density cholesterol, vitamin D, thyroid-stimulating hormone (TSH), and CRP - ISPM Blood pressure Undiagnosed disease Sub-sample (N=2086) Anthropometric measures: weight, height, knee height, waist and hip circumference Physical performance measures: balance, walk test, and muscle strength The targeted sub-sample was the full sample in four states: Rural state Urban state High-US-migration state High diabetes state

22 Sample Total sample N = 18,465 Sub-sample N = 2086 Age 50 years N = 1930 Sample= Missing in HbA1c = 46 - Self-reported diabetes in 2001 or 2002 = 14 - Missing information in selfreported diabetes 2012 = 8 No - Self-reported Diabetes N = 1440 Yes - Self-reported Diabetes N = 421

23 Undiagnosed disease Outcome Undiagnosed diabetes - A1c 6.5% (Finger Prick) - AC1 Now - NGSP certified Advantage: - No need for fasting - Average of glucose in the last 4 months Limitations: - Conditions that affect red blood cell turnover (hemolysis, blood loss) and hemoglobin variants - Patients with Kidney disease - High cost

24 Undiagnosed disease Overall percent of undiagnosed diabetes % Normal (HbA1C < 6.5) 23.3 Undiagnosed diabetes (HbA1c >=6.5)

25 Undiagnosed disease Descriptive characteristics Normal (HbA1c 6.5) Undiagnosed diabetes (HbA1c 6.5) Age (years) mean (SD) 63.6 (9.9) 63.7 (9.6) 50 to < (43.1) 130 (38.7) 60 to < (30.6) 122 (36.3) 70 to < (17.8) 59 (17.6) >=80 94 (8.5) 25 (7.4) Female 619 (56.1) 202 (60.1) Married 726 (65.8) 230 (68.5) Years of formal education 6.1 (4.9) 5.8 (4.3) mean (SD) * No education 174 (15.9) 42 (12.5) 1-5 years 309 (28.3) 100 (29.8) 6 years 236 (21.6) 90 (26.9) >=7 years 374 (34.2) 103 (30.8) * p-value < 0.05

26 Undiagnosed disease Descriptive characteristics Normal (HbA1c 6.5) Undiagnosed diabetes (HbA1c 6.5) Family history of diabetes 320 (30.8) 110 (34.2) Residence (urban versus 634 (57.4) 199 (59.2) rural) High U.S. migration state * 638 (57.8) 156 (46.4) Family history of diabetes 196 (17.8) 59 (17.6) Physical Activity 94 (8.5) 25 (7.4) Smoking Status Never 677 (61.3) 211 (62.8) Ever 282 (25.5) 79 (23.5) Current 145 (13.1) 46 (13.7) Hypertension 412 (37.5) 134 (40.0) Stroke 18 (1.6) 5 (1.5) Heart Attack 28 (2.5) 8 (2.4) * p-value < 0.05

27 Undiagnosed disease Descriptive characteristics BMI(Kg/m 2 ) category * Normal (HbA1c 6.5) Undiagnosed diabetes (HbA1c 6.5) Normal (18.5 to <25) 308 (28.4) 41 (12.4) Overweight (25 to <30) 434 (39.9) 125 (37.8) Obese ( 30) 344 (31.7) 165 (49.9) High Waist Circumference * 596 (54.7) 245 (73.8) High Waist Hip Ratio 944 (86.7) 304 (91.6) Physician visits 863 (78.2) 273 (81.3) Insurance coverage 918 (83.3) 287 (85.4) Diabetes screening 732 (66.3) 236 (70.2) * p-value < 0.05 High WC = >102 cm in men and >88 cm in women. High WHR = >90 in men and >85 in women

28 Undiagnosed disease Multivariate analysis OR (95% CI) Physical activity 0.69 ( ) High U.S. migration state 0.53 ( ) BMI(Kg/m 2 ) category Normal (18.5 to <25) Reference Overweight (25 to <30) 1.74 ( ) Obese ( 30) 2.56 ( ) High Waist Circumference 1.59 ( ) High WC = >102 cm in men and >88 cm in women

29 Surrogate marker Glycemic control Diabetes (N=421) % Good control (HbA1c < 7) Poor control (HBA1c >=7) Decreased risk of microvascular complications

30 Multivariate analysis Good glycemic control HbA1c <7 OR (95% CI) Age 65 years 2.35 ( ) Residence (urban versus rural) 2.00 ( ) Diabetes treatment None Reference Oral hypoglycemic 0.42 ( ) Insulin or /and oral hypoglycemic 0.14 ( )

31 % Self-reported diabetes 23.2 % 27.1 Good control (HbA1c < 7) 72.9 Poor control (HBA1c >=7) No Self-reported diabetes 76.8 % 20.1 Normal HbA1c < Prediabetes HbA1c ) 23.3 Undiagnosed Diabetes - HbA1c >= 6.5

32 Undiagnosed disease Summary Percent of undiagnosed diabetes (23.3%) Physical activity and high migration state - less risk for undiagnosed diabetes Total and abdominal obesity - high risk for undiagnosed diabetes Only 23.3 % - good glycemic control aged 65 years and older and urban residence

33 Undiagnosed disease Implications (Diabetes prevention) Weight loss of 7% of body weight Increase physical activity to at least 150 min/week of moderate activity such as walking Metformin therapy for prevention of type 2 diabetes may be considered in those with IGT, IFG, or an A1C %, especially for those with BMI 35 kg/m2 and those aged 60 years Screening for and treatment of modifiable risk factors for CVD is suggested Better control of diabetes

34 Acknowledgment This study was supported by the National Institutes of Health (R01-AG018016, R. Wong, PI)

Janice Lazear, DNP, FNP-C, CDE DIAGNOSIS AND CLASSIFICATION OF DIABETES

Janice Lazear, DNP, FNP-C, CDE DIAGNOSIS AND CLASSIFICATION OF DIABETES Janice Lazear, DNP, FNP-C, CDE DIAGNOSIS AND CLASSIFICATION OF DIABETES Objectives u At conclusion of the lecture the participant will be able to: 1. Differentiate between the classifications of diabetes

More information

Dr Aftab Ahmad Consultant Diabetologist at Royal Liverpool University Hospital Regional Diabetes Network Lead

Dr Aftab Ahmad Consultant Diabetologist at Royal Liverpool University Hospital Regional Diabetes Network Lead Dr Aftab Ahmad Consultant Diabetologist at Royal Liverpool University Hospital Regional Diabetes Network Lead Today s Presentation HbA1c & diagnosing Diabetes What is Impaired Glucose & IGR? Implications

More information

Gestational Diabetes: Long Term Metabolic Consequences. Outline 5/27/2014

Gestational Diabetes: Long Term Metabolic Consequences. Outline 5/27/2014 Gestational Diabetes: Long Term Metabolic Consequences Gladys (Sandy) Ramos, MD Associate Clinical Professor Maternal Fetal Medicine Outline Population rates of obesity and T2DM Obesity and metabolic syndrome

More information

Clinical Practice Guidelines for Diabetes Management

Clinical Practice Guidelines for Diabetes Management Clinical Practice Guidelines for Diabetes Management Diabetes is a disease in which blood glucose levels are above normal. Over the years, high blood glucose damages nerves and blood vessels, which can

More information

The Metabolic Syndrome: Is It A Valid Concept? YES

The Metabolic Syndrome: Is It A Valid Concept? YES The Metabolic Syndrome: Is It A Valid Concept? YES Congress on Diabetes and Cardiometabolic Health Boston, MA April 23, 2013 Edward S Horton, MD Joslin Diabetes Center Harvard Medical School Boston, MA

More information

Association between arterial stiffness and cardiovascular risk factors in a pediatric population

Association between arterial stiffness and cardiovascular risk factors in a pediatric population + Association between arterial stiffness and cardiovascular risk factors in a pediatric population Maria Perticone Department of Experimental and Clinical Medicine University Magna Graecia of Catanzaro

More information

Objectives 10/11/2013. Diabetes- The Real Cost of Sugar. Diabetes 101: What is Diabetes. By Ruth Nekonchuk RD CDE LMNT

Objectives 10/11/2013. Diabetes- The Real Cost of Sugar. Diabetes 101: What is Diabetes. By Ruth Nekonchuk RD CDE LMNT Diabetes- The Real Cost of Sugar By Ruth Nekonchuk RD CDE LMNT Objectives To explain diabetes To explain the risks of diabetes To enumerate the cost of diabetes to our country To enumerate the cost of

More information

Standards of Medical Care in Diabetes 2016

Standards of Medical Care in Diabetes 2016 Standards of Medical Care in Diabetes 2016 Care Delivery Systems 33-49% of patients still do not meet targets for A1C, blood pressure, or lipids. 14% meet targets for all A1C, BP, lipids, and nonsmoking

More information

V. N. Karazin Kharkiv National University Department of internal medicine Golubkina E.O., ass. of prof., Shanina I. V., ass. of prof.

V. N. Karazin Kharkiv National University Department of internal medicine Golubkina E.O., ass. of prof., Shanina I. V., ass. of prof. V. N. Karazin Kharkiv National University Department of internal medicine Golubkina E.O., ass. of prof., Shanina I. V., ass. of prof., Macharinskaya O.S., ass. of prof; Supervisor: prof. Yabluchanskiy

More information

HHS Public Access Author manuscript Ann Epidemiol. Author manuscript; available in PMC 2017 March 01.

HHS Public Access Author manuscript Ann Epidemiol. Author manuscript; available in PMC 2017 March 01. Prediabetes, undiagnosed diabetes, and diabetes among Mexican adults: findings from the Mexican Health and Aging Study Amit Kumar, PT, MPH, PhD a,b,*, Rebeca Wong, PhD b,c, Kenneth J. Ottenbacher, PhD,

More information

Epidemiology of Diabetes Mellitus in Asia

Epidemiology of Diabetes Mellitus in Asia Epidemiology of Diabetes Mellitus in Asia Nam H. Cho Professor of Preventive Medicine Director of Clinical Epidemiology Ajou University School of Medicine and Hospital, Suwon Korea President-elect of International

More information

Public Health and Nutrition in Older Adults. Patricia P. Barry, MD, MPH Merck Institute of Aging & Health and George Washington University

Public Health and Nutrition in Older Adults. Patricia P. Barry, MD, MPH Merck Institute of Aging & Health and George Washington University Public Health and Nutrition in Older Adults Patricia P. Barry, MD, MPH Merck Institute of Aging & Health and George Washington University Public Health and Nutrition in Older Adults n Overview of nutrition

More information

CHAPTER 3 DIABETES MELLITUS, OBESITY, HYPERTENSION AND DYSLIPIDEMIA IN ADULT CENTRAL KERALA POPULATION

CHAPTER 3 DIABETES MELLITUS, OBESITY, HYPERTENSION AND DYSLIPIDEMIA IN ADULT CENTRAL KERALA POPULATION CHAPTER 3 DIABETES MELLITUS, OBESITY, HYPERTENSION AND DYSLIPIDEMIA IN ADULT CENTRAL KERALA POPULATION 3.1 BACKGROUND Diabetes mellitus (DM) and impaired glucose tolerance (IGT) have reached epidemic proportions

More information

Vitamin D supplementation of professionally active adults

Vitamin D supplementation of professionally active adults Vitamin D supplementation of professionally active adults VITAMIN D MINIMUM, MAXIMUM, OPTIMUM FRIDAY, SEPTEMBER 22 ND 2017 Samantha Kimball, PhD, MLT Research Director Pure North S Energy Foundation The

More information

Measurement error of HbA1c for screening for type 2 diabetes among healthy Japanese adults

Measurement error of HbA1c for screening for type 2 diabetes among healthy Japanese adults Preventing Overdiagnosis 2016 in Barcelona ( 20-22 September, 2016 ) Measurement error of HbA1c for screening for type 2 diabetes among healthy Japanese adults Kuniyoshi Hayashi 1, 2, Sachiko Ohde 1, Gautam

More information

BaptistHealth_FEB2014 1

BaptistHealth_FEB2014 1 Hispanic Health Disparities in Diabetes: Implications for CVD Prevention Neil Schneiderman University of Miami Baptist Health South Florida 12 th Annual CVD Prevention Symposium Miami Beach, Florida February

More information

Patient: Shawn Baker March 06, 2018

Patient: Shawn Baker March 06, 2018 Mr. Shawn Baker Dear Participant: Our team at SpecialtyHealth has received your lab work and the results have been reviewed. In this letter you will find a summary of the results along with numerous charts

More information

Epidemiology of Diabetes, Impaired Glucose Homeostasis and Cardiovascular Risk. Eberhard Standl

Epidemiology of Diabetes, Impaired Glucose Homeostasis and Cardiovascular Risk. Eberhard Standl Epidemiology of Diabetes, Impaired Glucose Homeostasis and Cardiovascular Risk Eberhard Standl European Heart House Sophia Antipolis Thursday, June 17, 2010 IDF Diabetes Atlas 2009: Global Numbers Still

More information

DIABETES. A growing problem

DIABETES. A growing problem DIABETES A growing problem Countries still grappling with infectious diseases such as tuberculosis, HIV/AIDS and malaria now face a double burden of disease Major social and economic change has brought

More information

This slide set provides an overview of the impact of type 1 and type 2 diabetes mellitus in the United States, focusing on epidemiology, costs both

This slide set provides an overview of the impact of type 1 and type 2 diabetes mellitus in the United States, focusing on epidemiology, costs both This slide set provides an overview of the impact of type 1 and type 2 diabetes mellitus in the United States, focusing on epidemiology, costs both direct and indirect and the projected burden of diabetes,

More information

The role of glycated hemoglobin in the screening and diagnosis of renal posttransplantation diabetes

The role of glycated hemoglobin in the screening and diagnosis of renal posttransplantation diabetes Federal University of Rio Grande do Sul Graduate Program in Endocrinology Brazil The role of glycated hemoglobin in the screening and diagnosis of renal posttransplantation diabetes Ana Laura Pimentel

More information

Test5, Here is Your My5 to Health Profile with Metabolic Syndrome Insight

Test5, Here is Your My5 to Health Profile with Metabolic Syndrome Insight Test5, Here is Your My5 to Health Profile with Metabolic Syndrome Insight Quest, Quest Diagnostics, the associated logo, and all associated Quest Diagnostics marks are the registered trademarks of Quest

More information

Diabetes Management and Considerations for the Indian Culture

Diabetes Management and Considerations for the Indian Culture Diabetes Management and Considerations for the Indian Culture Ramachandra G. Naik, MD Senior Medical Director Worldwide Clinical Affairs Johnson & Johnson Diabetes Solutions Companies September 24, 2015

More information

Diabetes mellitus is diagnosed and characterized by chronic hyperglycemia. The effects of

Diabetes mellitus is diagnosed and characterized by chronic hyperglycemia. The effects of Focused Issue of This Month Early Diagnosis of Diabetes Mellitus Hyun Shik Son, MD Department of Internal Medicine, The Catholic University of Korea College of Medicine E - mail : sonhys@gmail.com J Korean

More information

Pre Diabetes Screening in Primary Care

Pre Diabetes Screening in Primary Care University of San Diego Digital USD Doctor of Nursing Practice Final Manuscripts Theses and Dissertations Spring 5-21-2016 Pre Diabetes Screening in Primary Care Christine Rieger crieger@sandiego.edu Follow

More information

The National Diabetes Prevention Program in Washington State March 2012

The National Diabetes Prevention Program in Washington State March 2012 The National Diabetes Prevention Program in Washington State March 2012 Session Objectives 1. Overview of pre-diabetes. 2. Describe the Diabetes Prevention Program (DPP). 3. Eligibility for the DPP. 4.

More information

Tuberculosis and Diabetes

Tuberculosis and Diabetes Tuberculosis and Diabetes National Web-based Seminar Francis J. Curry National TB Center San Francisco, California December 1, 29 Jane Kelly, M.D. Centers for Disease Control and Prevention jkelly@cdc.gov

More information

Risk Monitor How-to guide

Risk Monitor How-to guide Risk Monitor How-to guide Contents INTRODUCTION... 3 RESEARCH METHODS... 4 THE RISK MONITOR... 5 STEP-BY-STEP GUIDE... 6 Definitions... 7 PHASE ONE STUDY PLANNING... 8 Define the target population... 8

More information

American Diabetes Association Standards of Medical Care in Diabetes 2018: Latest Updates

American Diabetes Association Standards of Medical Care in Diabetes 2018: Latest Updates American Diabetes Association Standards of Medical Care in Diabetes 2018: Latest Updates Juan Pablo Frias, MD President and CEO, National Research Institute, Los Angeles, CA Clinical Faculty, University

More information

Metabolic Syndrome. Shon Meek MD, PhD Mayo Clinic Florida Endocrinology

Metabolic Syndrome. Shon Meek MD, PhD Mayo Clinic Florida Endocrinology Metabolic Syndrome Shon Meek MD, PhD Mayo Clinic Florida Endocrinology Disclosure No conflict of interest No financial disclosure Does This Patient Have Metabolic Syndrome? 1. Yes 2. No Does This Patient

More information

Diabetes: Staying Two Steps Ahead. The prevalence of diabetes is increasing. What causes Type 2 diabetes?

Diabetes: Staying Two Steps Ahead. The prevalence of diabetes is increasing. What causes Type 2 diabetes? Focus on CME at the University of University Manitoba of Manitoba : Staying Two Steps Ahead By Shagufta Khan, MD; and Liam J. Murphy, MD The prevalence of diabetes is increasing worldwide and will double

More information

Evaluation of Different Risk Factors for Early Diagnosis of Diabetes Mellitus

Evaluation of Different Risk Factors for Early Diagnosis of Diabetes Mellitus IJMS Vol 29, No 1, March 2004 Original Article Evaluation of Different Risk Factors for Early Diagnosis of Diabetes Mellitus S. Habibi Moeini, P. Mirmiran, Y. Mehrabi, F. Azizi Abstract Background: The

More information

Lack of documentation on overweight & obese status in patients admitted to the coronary care unit: Results from the CCU study

Lack of documentation on overweight & obese status in patients admitted to the coronary care unit: Results from the CCU study Lack of documentation on overweight & obese status in patients admitted to the coronary care unit: Results from the CCU study Meriam F. Caboral,, RN, MSN, NP-C Clinical Coordinator Heart Failure Components

More information

The Metabolic Syndrome Update The Metabolic Syndrome Update. Global Cardiometabolic Risk

The Metabolic Syndrome Update The Metabolic Syndrome Update. Global Cardiometabolic Risk The Metabolic Syndrome Update 2018 Marc Cornier, M.D. Professor of Medicine Division of Endocrinology, Metabolism & Diabetes Anschutz Health and Wellness Center University of Colorado School of Medicine

More information

Adult Diabetes Clinician Guide NOVEMBER 2017

Adult Diabetes Clinician Guide NOVEMBER 2017 Kaiser Permanente National CLINICAL PRACTICE GUIDELINES Adult Diabetes Clinician Guide Introduction NOVEMBER 2017 This evidence-based guideline summary is based on the 2017 KP National Diabetes Guideline.

More information

2013 ACC/AHA Guidelines on the Assessment of Atherosclerotic Cardiovascular Risk: Overview and Commentary

2013 ACC/AHA Guidelines on the Assessment of Atherosclerotic Cardiovascular Risk: Overview and Commentary 2013 ACC/AHA Guidelines on the Assessment of Atherosclerotic Cardiovascular Risk: Overview and Commentary The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease Becky McKibben, MPH; Seth

More information

Chief of Endocrinology East Orange General Hospital

Chief of Endocrinology East Orange General Hospital Targeting the Incretins System: Can it Improve Our Ability to Treat Type 2 Diabetes? Darshi Sunderam, MD Darshi Sunderam, MD Chief of Endocrinology East Orange General Hospital Age-adjusted Percentage

More information

Screening and Diagnosis of Diabetes Mellitus in Taiwan

Screening and Diagnosis of Diabetes Mellitus in Taiwan Screening and Diagnosis of Diabetes Mellitus in Taiwan Hung-Yuan Li, MD, MMSc, PhD Attending Physician, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Associate Professor,

More information

Modified version focused on CCNC Quality Measures and Feedback Processes

Modified version focused on CCNC Quality Measures and Feedback Processes Executive Summary: Standards of Medical Care in Diabetes 2010 Modified version focused on CCNC Quality Measures and Feedback Processes See http://care.diabetesjournals.org/content/33/supplement_1/s11.full

More information

Diabetes Monitoring: Easy as A-1-C An educational webinar sponsored by Siemens Healthcare Diagnostics

Diabetes Monitoring: Easy as A-1-C An educational webinar sponsored by Siemens Healthcare Diagnostics Wednesday, January 14th at 1:00 PM EST Diabetes Monitoring: Easy as A-1-C An educational webinar sponsored by Siemens Healthcare Diagnostics Dr. Nancy Haley Senior Clinical Consultant Agenda Introductions

More information

Chapter 18. Diet and Health

Chapter 18. Diet and Health Chapter 18 Diet and Health Risk Factors and Chronic Diseases Interrelationships among Chronic Diseases Chronic Disease Heart Disease and Stroke Hypertension Cancer Diabetes The Formation of Plaques in

More information

Eugene Barrett M.D., Ph.D. University of Virginia 6/18/2007. Diagnosis and what is it Glucose Tolerance Categories FPG

Eugene Barrett M.D., Ph.D. University of Virginia 6/18/2007. Diagnosis and what is it Glucose Tolerance Categories FPG Diabetes Mellitus: Update 7 What is the unifying basis of this vascular disease? Eugene J. Barrett, MD, PhD Professor of Internal Medicine and Pediatrics Director, Diabetes Center and GCRC Health System

More information

Guidelines on cardiovascular risk assessment and management

Guidelines on cardiovascular risk assessment and management European Heart Journal Supplements (2005) 7 (Supplement L), L5 L10 doi:10.1093/eurheartj/sui079 Guidelines on cardiovascular risk assessment and management David A. Wood 1,2 * 1 Cardiovascular Medicine

More information

CLINICAL OUTCOME Vs SURROGATE MARKER

CLINICAL OUTCOME Vs SURROGATE MARKER CLINICAL OUTCOME Vs SURROGATE MARKER Statin Real Experience Dr. Mostafa Sherif Senior Medical Manager Pfizer Egypt & Sudan Objective Difference between Clinical outcome and surrogate marker Proper Clinical

More information

OBESITY IN PRIMARY CARE

OBESITY IN PRIMARY CARE OBESITY IN PRIMARY CARE Obesity- definition Is a chronic disease In ICD 10 E66 Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health. Obesity is a leading

More information

2010 ADA Guidelines: 1. Diagnostic Criteria for DM 2. Categories of increased risk of DM. Gerti Tashko, M.D. DM Journal Club 1/21/2010

2010 ADA Guidelines: 1. Diagnostic Criteria for DM 2. Categories of increased risk of DM. Gerti Tashko, M.D. DM Journal Club 1/21/2010 2010 ADA Guidelines: 1. Diagnostic Criteria for DM 2. Categories of increased risk of DM Gerti Tashko, M.D. DM Journal Club 1/21/2010 NEW: Diagnosis with A1c 6.5% Cut point of A1c 6.5% diagnoses 33% less

More information

Donna Tomky, MSN, C-ANP, CDE, FAADE Albuquerque, New Mexico

Donna Tomky, MSN, C-ANP, CDE, FAADE Albuquerque, New Mexico Donna Tomky, MSN, C-ANP, CDE, FAADE Albuquerque, New Mexico Presented in Collaboration with New Mexico Health Care Takes On Diabetes Discuss the burden and challenges prediabetes presents in New Mexico.

More information

Metabolic Syndrome Update The Metabolic Syndrome: Overview. Global Cardiometabolic Risk

Metabolic Syndrome Update The Metabolic Syndrome: Overview. Global Cardiometabolic Risk Metabolic Syndrome Update 21 Marc Cornier, M.D. Associate Professor of Medicine Division of Endocrinology, Metabolism & Diabetes University of Colorado Denver Denver Health Medical Center The Metabolic

More information

METABOLIC SYNDROME IN REPRODUCTIVE FEMALES

METABOLIC SYNDROME IN REPRODUCTIVE FEMALES METABOLIC SYNDROME IN REPRODUCTIVE FEMALES John J. Orris, D.O., M.B.A Division Head, Reproductive Endocrinology & Infertility, Main Line Health System Associate Professor, Drexel University College of

More information

Fasting Glucose, Obesity, and Metabolic Syndrome as Predictors of Type 2 Diabetes: The Cooper Center Longitudinal Study

Fasting Glucose, Obesity, and Metabolic Syndrome as Predictors of Type 2 Diabetes: The Cooper Center Longitudinal Study Fasting Glucose, Obesity, and Metabolic Syndrome as Predictors of Type 2 Diabetes: The Cooper Center Longitudinal Study Laura F. DeFina, MD,* Gloria Lena Vega, PhD,Þ David Leonard, PhD,Þ and Scott M. Grundy,

More information

Association between Raised Blood Pressure and Dysglycemia in Hong Kong Chinese

Association between Raised Blood Pressure and Dysglycemia in Hong Kong Chinese Diabetes Care Publish Ahead of Print, published online June 12, 2008 Raised Blood Pressure and Dysglycemia Association between Raised Blood Pressure and Dysglycemia in Hong Kong Chinese Bernard My Cheung,

More information

Energy Balance and Macronutrient Distribution in Relation to CRP and HbA1c Levels Among Patients with Type 2 Diabetes

Energy Balance and Macronutrient Distribution in Relation to CRP and HbA1c Levels Among Patients with Type 2 Diabetes Energy Balance and Macronutrient Distribution in Relation to CRP and HbA1c Levels Among Patients with Type 2 Diabetes Hiba Bawadi, PhD, CNS, FACN OUTLINE Background and definitions Research Objective Methods

More information

Discussion points. The cardiometabolic connection. Cardiometabolic Risk Management in the Primary Care Setting

Discussion points. The cardiometabolic connection. Cardiometabolic Risk Management in the Primary Care Setting Session #5 Cardiometabolic Risk Management in the Primary Care Setting Sonja Reichert, MD MSc FCFP FACPM Betty Harvey, RNEC BScN MScN Amanda Mikalachki, RN BScN CDE S Discussion points Whom should we be

More information

Know Your Numbers. Your guide to maintaining good health. Helpful information from Providence Medical Center and Saint John Hospital

Know Your Numbers. Your guide to maintaining good health. Helpful information from Providence Medical Center and Saint John Hospital Know Your Numbers Your guide to maintaining good health Helpful information from Providence Medical Center and Saint John Hospital If it has been awhile since your last check up and you are searching for

More information

Effect of bitter gourd clinical trial in prediabetics: blind, randomised, cross over trial in India

Effect of bitter gourd clinical trial in prediabetics: blind, randomised, cross over trial in India Effect of bitter gourd clinical trial in prediabetics: blind, randomised, cross over trial in India Dr.M. Amirthaveni Subramanian & Dr.S.Premakumari Department of Food Science and Nutrition Avinashilingam

More information

Total risk management of Cardiovascular diseases Nobuhiro Yamada

Total risk management of Cardiovascular diseases Nobuhiro Yamada Nobuhiro Yamada The worldwide burden of cardiovascular diseases (WHO) To prevent cardiovascular diseases Beyond LDL Multiple risk factors With common molecular basis The Current Burden of CVD CVD is responsible

More information

STATE OF THE STATE: TYPE II DIABETES

STATE OF THE STATE: TYPE II DIABETES STATE OF THE STATE: TYPE II DIABETES HENRY DRISCOLL, MD, CHIEF of ENDOCRINOLOGY MARSHALL U, CHERTOW DIABETES CENTER, HUNTINGTON VAMC HEATHER VENOY, RD, LD, CDE DIETITIAN, DIABETES EDUCATOR, CHERTOW DIABETES

More information

Cardiovascular Complications of Diabetes

Cardiovascular Complications of Diabetes VBWG Cardiovascular Complications of Diabetes Nicola Abate, M.D., F.N.L.A. Professor and Chief Division of Endocrinology and Metabolism The University of Texas Medical Branch Galveston, Texas Coronary

More information

Clinical Study Synopsis

Clinical Study Synopsis Clinical Study Synopsis This Clinical Study Synopsis is provided for patients and healthcare professionals to increase the transparency of Bayer's clinical research. This document is not intended to replace

More information

Selected Overweight- and Obesity- Related Health Disorders

Selected Overweight- and Obesity- Related Health Disorders Selected Overweight- and Obesity- Related Health Disorders HIGHLIGHTS Obesity and overweight are predisposing factors for the development of type 2 diabetes mellitus, coronary heart disease, stroke, osteoarthritis

More information

Analytical Methods: the Kidney Early Evaluation Program (KEEP) The Kidney Early Evaluation program (KEEP) is a free, community based health

Analytical Methods: the Kidney Early Evaluation Program (KEEP) The Kidney Early Evaluation program (KEEP) is a free, community based health Analytical Methods: the Kidney Early Evaluation Program (KEEP) 2000 2006 Database Design and Study Participants The Kidney Early Evaluation program (KEEP) is a free, community based health screening program

More information

Diabetes Mellitus and the Dental Healthcare Professional

Diabetes Mellitus and the Dental Healthcare Professional Diabetes Mellitus and the Dental Healthcare Professional Jerry A. Brown DMD, CDE University of South Florida Department of Internal Medicine jabrown7@health.usf.edu Learning Objectives Diabetes- The Disease

More information

Diabetes Mellitus in the Pediatric Patient

Diabetes Mellitus in the Pediatric Patient Diabetes Mellitus in the Pediatric Patient William Bryant, M.D. Chief of Section Pediatric Endocrinology Children s Hospital at Scott & White Texas A&M University Temple, Texas Disclosures None Definitions

More information

The Diabetes Prevention Program: Call for Action

The Diabetes Prevention Program: Call for Action The Diabetes Prevention Program: Call for Action Osama Hamdy, MD, PhD, FACE Medical Director, Obesity Clinical Program, Director of Inpatient Diabetes Management, Joslin Diabetes Center Harvard Medical

More information

Module 2: Metabolic Syndrome & Sarcopenia. Lori Kennedy Inc & Beyond

Module 2: Metabolic Syndrome & Sarcopenia. Lori Kennedy Inc & Beyond Module 2: Metabolic Syndrome & Sarcopenia 1 What You Will Learn Sarcopenia Metabolic Syndrome 2 Sarcopenia Term utilized to define the loss of muscle mass and strength that occurs with aging Progressive

More information

Why Do We Treat Obesity? Epidemiology

Why Do We Treat Obesity? Epidemiology Why Do We Treat Obesity? Epidemiology Epidemiology of Obesity U.S. Epidemic 2 More than Two Thirds of US Adults Are Overweight or Obese 87.5 NHANES Data US Adults Age 2 Years (Crude Estimate) Population

More information

Ischemic Heart and Cerebrovascular Disease. Harold E. Lebovitz, MD, FACE Kathmandu November 2010

Ischemic Heart and Cerebrovascular Disease. Harold E. Lebovitz, MD, FACE Kathmandu November 2010 Ischemic Heart and Cerebrovascular Disease Harold E. Lebovitz, MD, FACE Kathmandu November 2010 Relationships Between Diabetes and Ischemic Heart Disease Risk of Cardiovascular Disease in Different Categories

More information

Sarcopenia - a Regulatory Perspective

Sarcopenia - a Regulatory Perspective Sarcopenia - a Regulatory Perspective Dragos Roman, M.D. Team Leader Division of Metabolism and Endocrinology Products, Office of New Drugs, Center for Drug Evaluation and Research, FDA May 11, 2012 1

More information

KEY COMPONENTS. Metabolic Risk Cardiovascular Risk Vascular Inflammation Markers

KEY COMPONENTS. Metabolic Risk Cardiovascular Risk Vascular Inflammation Markers CardioMetabolic Risk Poor blood sugar regulation and unhealthy triglyceride and lipoprotein levels often present long before the diagnosis of type 2 Diabetes. SpectraCell s CardioMetabolic and Pre-Diabetes

More information

Current Diabetes Care for Internists:2011

Current Diabetes Care for Internists:2011 Current Diabetes Care for Internists:2011 Petch Rawdaree, DM, MSc, DLSHTM Faculty of Medicine Vajira Hospital University of Bangkok Metropolis 19 th January 2011 ก ก 1. ก ก ก ก 2. ก ก ก ก ก 3. ก ก ก ก

More information

Non alcoholic fatty liver disease and atherosclerosis Raul Santos, MD

Non alcoholic fatty liver disease and atherosclerosis Raul Santos, MD Non alcoholic fatty liver disease and atherosclerosis Raul Santos, MD Sao Paulo Medical School Hospital Sao Paulo, Brazil Disclosure Honoraria received for consult and/or speaker : Astra Zeneca, Amgen,

More information

Diabetes Mellitus: Evaluation and Care Management

Diabetes Mellitus: Evaluation and Care Management Diabetes Mellitus: Evaluation and Care Management Michael King, MD Assistant Professor Residency Program Director University of Kentucky Dept. of Family & Community Medicine Learning Objectives 1. Review

More information

Prevalence of Diabetes Mellitus and Pre-Diabetes in the Philippines: A Sub-study of the 7 th National Nutrition and Health Survey (2008)

Prevalence of Diabetes Mellitus and Pre-Diabetes in the Philippines: A Sub-study of the 7 th National Nutrition and Health Survey (2008) Philippine Journal of Internal Medicine Original Paper Prevalence of Diabetes Mellitus and Pre-Diabetes in the Philippines: A Sub-study of the 7 th National Nutrition and Health Survey (2008) Cecilia A.

More information

5. Cardiovascular Disease & Stroke

5. Cardiovascular Disease & Stroke 5. Cardiovascular Disease & Stroke 64: Self-Reported Heart Disease 66: Heart Disease Management 68: Heart Disease Mortality 70: Heart Disease Mortality Across Life Span 72: Stroke Mortality 185: Map 3:

More information

Appendix This appendix was part of the submitted manuscript and has been peer reviewed. It is posted as supplied by the authors.

Appendix This appendix was part of the submitted manuscript and has been peer reviewed. It is posted as supplied by the authors. Appendix This appendix was part of the submitted manuscript and has been peer reviewed. It is posted as supplied by the authors. Appendix to: Banks E, Crouch SR, Korda RJ, et al. Absolute risk of cardiovascular

More information

Standards of Care in Diabetes What's New? Veronica Brady, FNP-BC, PhD, BC-ADM,CDE Karmella Thomas, RD, LD,CDE

Standards of Care in Diabetes What's New? Veronica Brady, FNP-BC, PhD, BC-ADM,CDE Karmella Thomas, RD, LD,CDE Standards of Care in Diabetes 2016-- What's New? Veronica Brady, FNP-BC, PhD, BC-ADM,CDE Karmella Thomas, RD, LD,CDE Terminology No longer using the term diabetic. Diabetes does not define people. People

More information

SYNOPSIS OF RESEARCH REPORT (PROTOCOL BC20779)

SYNOPSIS OF RESEARCH REPORT (PROTOCOL BC20779) TITLE OF THE STUDY / REPORT No. / DATE OF REPORT INVESTIGATORS / CENTERS AND COUNTRIES Clinical Study Report Protocol BC20779: Multicenter, double-blind, randomized, placebo-controlled, dose ranging phase

More information

Living Well with Diabetes

Living Well with Diabetes Living Well with Diabetes What is diabetes? Diabetes Overview Diabetes is a disorder of the way the body uses food for growth and energy. Most of the food people eat is broken down into glucose, the form

More information

Diabetes in Asian Americans

Diabetes in Asian Americans Diabetes in Asian Americans www.screenat23.org Winston F. Wong, MD National Council of Asian Pacific Islander Physicians www.ncapip.org American Diabetes Association Joslin Diabetes Center National Council

More information

Rehabilitation and Research Training Center on Secondary Conditions in Individuals with SCI. James S. Krause, PhD

Rehabilitation and Research Training Center on Secondary Conditions in Individuals with SCI. James S. Krause, PhD Disclosure The contents of this presentation were developed with support from educational grants from the Department of Education, NIDRR grant numbers H133B090005, H133B970011 and H133G010160. However,

More information

Presenter Disclosure Information

Presenter Disclosure Information Prediabetes & Type 2 Diabetes Prevention Cari Ritter, PA-C Presenter Disclosure Information In compliance with the accrediting board policies, the American Diabetes Association requires the following disclosure

More information

Diabetes and Cardiovascular Risks in the Polycystic Ovary Syndrome

Diabetes and Cardiovascular Risks in the Polycystic Ovary Syndrome Diabetes and Cardiovascular Risks in the Polycystic Ovary Syndrome John E. Nestler, M.D. William Branch Porter Professor of Medicine Chair, Department of Internal Medicine Virginia Commonwealth University

More information

Know Your Number Aggregate Report Single Analysis Compared to National Averages

Know Your Number Aggregate Report Single Analysis Compared to National Averages Know Your Number Aggregate Report Single Analysis Compared to National s Client: Study Population: 2242 Population: 3,000 Date Range: 04/20/07-08/08/07 Version of Report: V6.2 Page 2 Study Population Demographics

More information

The Global Agenda for the Prevention of Diabetes: Research Opportunities

The Global Agenda for the Prevention of Diabetes: Research Opportunities The Global Agenda for the Prevention of Diabetes: Research Opportunities William H. Herman, MD, MPH Stefan S. Fajans/GlaxoSmithKline Professor of Diabetes Professor of Internal Medicine and Epidemiology

More information

Trends In CVD, Related Risk Factors, Prevention and Control In China

Trends In CVD, Related Risk Factors, Prevention and Control In China Trends In CVD, Related Risk Factors, Prevention and Control In China Youfa Wang, MD, MS, PhD Associate Professor Center for Human Nutrition Department of International Health Department of Epidemiology

More information

Magnetic resonance imaging, image analysis:visual scoring of white matter

Magnetic resonance imaging, image analysis:visual scoring of white matter Supplemental method ULSAM Magnetic resonance imaging, image analysis:visual scoring of white matter hyperintensities (WMHI) was performed by a neuroradiologist using a PACS system blinded of baseline data.

More information

Metabolic Syndrome in Asians

Metabolic Syndrome in Asians Metabolic Syndrome in Asians Alka Kanaya, MD Asst. Professor of Medicine, UCSF Asian CV Symposium, November 17, 2007 The Metabolic Syndrome Also known as: Syndrome X Insulin Resistance Syndrome The Deadly

More information

Schöttker et al. BMC Medicine (2016) 14:26 DOI /s

Schöttker et al. BMC Medicine (2016) 14:26 DOI /s Schöttker et al. BMC Medicine (2016) 14:26 DOI 10.1186/s12916-016-0570-1 RESEARCH ARTICLE HbA 1c levels in non-diabetic older adults No J-shaped associations with primary cardiovascular events, cardiovascular

More information

Detecting Type 2 diabetes and impaired glucose regulation using glycated hemoglobin in different populations

Detecting Type 2 diabetes and impaired glucose regulation using glycated hemoglobin in different populations Detecting Type 2 diabetes and impaired glucose regulation using glycated hemoglobin in different populations Practice Points Samiul A Mostafa 1, Kamlesh Khunti2, Balasubramanian Thiagarajan Srinivasan1,

More information

Eating Strategies to Improve Your Health

Eating Strategies to Improve Your Health Eating Strategies to Improve Your Health Canada s Population is Aging Canada s Aging Population, Health Canada 2002 Mortality is Due Primarily to Chronic Disease Canada s Aging Population, Health Canada

More information

Taking Steps to Control and Prevent Diabetes Zaida Belendez, ND, RN

Taking Steps to Control and Prevent Diabetes Zaida Belendez, ND, RN Taking Steps to Control and Prevent Diabetes Zaida Belendez, ND, RN Diabetes is a common, serious, and costly disease condition of elevated blood glucose (high blood sugar) that causes significant illness

More information

WILL YOU USE HBA1C TO SCREEN & MONITOR DIABETES? Dr. Amany Mousa

WILL YOU USE HBA1C TO SCREEN & MONITOR DIABETES? Dr. Amany Mousa WILL YOU USE HBA1C TO SCREEN & MONITOR DIABETES? Dr. Amany Mousa Diabetes is clinically well defined by glycation of proteins 1. True 2. false So far, diabetes has been defined as a clinical condition

More information

Effects of whole grain intake on weight changes, diabetes, and cardiovascular Disease

Effects of whole grain intake on weight changes, diabetes, and cardiovascular Disease Effects of whole grain intake on weight changes, diabetes, and cardiovascular Disease Simin Liu, MD, ScD Professor of Epidemiology and Medicine Director, Center for Global Cardiometabolic Health Brown

More information

Executive Summary: Standards of Medical Care in Diabetes 2010

Executive Summary: Standards of Medical Care in Diabetes 2010 E X E C U T I V E S U M M A R Y Executive Summary: Standards of Medical Care in Diabetes 2010 Current criteria for the diagnosis of diabetes A1C 6.5%: The test should be performed in a laboratory using

More information

Diabetes Update. Pam Allweiss, MD, MPH Centers for Disease Control and Prevention. Division of Diabetes Translation

Diabetes Update. Pam Allweiss, MD, MPH Centers for Disease Control and Prevention. Division of Diabetes Translation Diabetes Update Pam Allweiss, MD, MPH pca8@cdc.gov Centers for Disease Control and Prevention. Division of Diabetes Translation The findings and conclusions of this presentation are those of the presenter

More information

Common Diabetes-related Terms

Common Diabetes-related Terms Common Diabetes-related Terms A1C An A1C test measures a person's average blood glucose level over two to three months. Hemoglobin is the part of a red blood cell that carries oxygen to the cells and sometimes

More information

Director, Employee Health & Productivity. Coordinator, Employee Health & Productivity

Director, Employee Health & Productivity. Coordinator, Employee Health & Productivity Director, Employee Health & Productivity Coordinator, Employee Health & Productivity Table 2:. ChartE: Female HDL Cholesterol Risk Levels Optimal Borderline High Risk 80% 60% 40% 20% 0% LDL Cholesterol

More information

PREVALENCE OF METABOLİC SYNDROME İN CHİLDREN AND ADOLESCENTS

PREVALENCE OF METABOLİC SYNDROME İN CHİLDREN AND ADOLESCENTS PREVALENCE OF METABOLİC SYNDROME İN CHİLDREN AND ADOLESCENTS Mehmet Emre Atabek,MD,PhD Necmettin Erbakan University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology and

More information

Control n. Patient Int. n at Baseline (n at. Int. Type Specific Intervention

Control n. Patient Int. n at Baseline (n at. Int. Type Specific Intervention 1.1 BMI and Associated Risk Factors of T2DM 23867023 Casagrande Utility of the U.S. Preventive Services Task 2013 Cross-sectional NHANES Data from The goals of this study were to 7189 7189 adults who participated

More information

Diabetes Mellitus Aeromedical Considerations. Aviation Medicine Seminar Bucharest, Romania. 11 th to 15 th November 2013

Diabetes Mellitus Aeromedical Considerations. Aviation Medicine Seminar Bucharest, Romania. 11 th to 15 th November 2013 Diabetes Mellitus Aeromedical Considerations Aviation Medicine Seminar Bucharest, Romania. 11 th to 15 th November 2013 Metabolic, Nutritional or Endocrine disorders Applicants with metabolic, nutritional

More information