Building a Reputation with a Continuum of Care PhilosophyFriday, August 05, 2011
Vanderbilt is gaining recognition as a leading diabetes institution in part because it provides care for every type of diabetes and throughout patients’ lifetimes.
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
In the latest U.S. News and World Report’s Best Hospitals’ Survey, the Vanderbilt University Medical Center was ranked 14th for its diabetes and endocrinology nationally. This is an important measure of success as Vanderbilt has put a significant emphasis on building its diabetes program in recent years.
One way in which Vanderbilt has distinguished itself is in its philosophy of treating diabetes patients throughout the continuum of life: from pregnancy into adulthood. For example, Vanderbilt has developed a new protocol in screening every woman for gestational diabetes much earlier in her pregnancy than what has been the universally accepted protocol. While this form of diabetes is transient, researchers are beginning to understand the significant risks of the mother developing diabetes in subsequent pregnancies and in the babies’ lives as well.
Possibly the best example of the continuum of life philosophy at Vanderbilt can be witnessed at its Eskind Diabetes Clinic, which provides care to both children and adults with diabetes. It has one of the largest pediatric diabetes programs in the U.S., treating nearly 2,000 children. So, when children become teens and are ready to take on the responsibility of more self-care they continue to be seen by doctors at Eskind, which can help make it a smoother transition during a typically difficult time in a teen with diabetes.
Additionally, its clinical expertise is not to be out done with active ongoing research and observational studies of extended family members. Vanderbilt is also one of the clinical centers for the Type 1 Diabetes TrialNet, which is an international network of centers investigating type 1 diabetes.
Separately, but related to the diabetes program, Vanderbilt has been developing its various transplant programs, and as such, some of these patients who undergo these procedures are developing post-transplant diabetes. The university has been caring for these vulnerable patients as well.
Shubhada Jagasia, MD (pictured, below, right), is an associate professor of medicine and associate program director of the Division of Diabetes, Endocrinology and Metabolism Vanderbilt University Medical Center at Vanderbilt University, and specializes in both gestational and post-transplant diabetes. Along with her clinical expertise, she oversees the curriculum and teaches in the university’s endocrinology program.
DiabetesCare.net recently caught up with Dr. Jagasia to find out some of the ways Vanderbilt has been distinguishing its diabetes program, and what she is doing in the care of gestational and post-transplant diabetes patients.
DiabetesCare.net: Can you provide an overview of your responsibilities at Vanderbilt University?
Dr. Jagasia: In addition to my clinical responsibilities and seeing patients, I teach a spectrum of students from premedical students all the way up to Endocrinology fellows. I am also in charge of the overview and planning of the clinical training of endocrine fellows, and I make sure the mandated requirements of the graduate medical education program are fulfilled.
DiabetesCare.net: Vanderbilt has one of the biggest pediatric diabetes programs in the country, and it also has been selected as one of the primary clinical centers for the Type 1 Diabetes TrialNet. What advantages does Vanderbilt have in housing both clinical care and research capabilities?
Dr. Jagasia: It is a huge advantage, and Vanderbilt has strategically positioned itself to not only provide excellent clinical care, but also research several aspects of diabetes. Pediatric endocrinology is a busy clinical program and patients are made aware about research opportunities. This awareness allows us to enroll more patients into research studies.
A very important component of TrialNet is the observational study of the natural progression of type 1 diabetes. This study enrolls patients and their close relatives because all of those relatives have a higher chance of harboring anti-bodies towards the pancreas that may or may not increase their chances of developing type 1 diabetes in their lifetimes. This enables them to study the natural course of the disease and makes them poised to participate in prevention trials. TrialNet has looked at trials using insulin and medications that modulate the immune system to see if they can alter the progression of type 1 diabetes.
DiabetesCare.net: Why does Eskind treat both adults and children?
Dr. Jagasia: One of the missions of this very high caliber clinic is to provide care throughout patients entire lives.
We have several families that make use of our multi-specialty, single -visit approach. We try to coordinate care so that patients’ families can see multi-providers on the same day. For example, we have patient families who drive several hours to come to Vanderbilt. These families can receive care for their child who has type 1 from the pediatric endocrinologist , and simultaneously, the parent can receive care from an adult endocrinologist. Also, if the mother is pregnant, she will be seen by a maternal fetal medicine obstetrician, who will provide excellent care during pregnancy.
Another big advantage to treating children and adults in the same facility is when patients transition from a pediatric to adult endocrinologist. Adolescent patients may often struggle with this transition. If these patients don’t get transitioned appropriately to an adult endocrinologist, they may not receive the appropriate care, thereby increasing their risk of complications. Having this transition happen in the same clinic, makes it significantly easier on these patients.
DiabetesCare.net: Gestational diabetes has recently been in the public recently with the news that a 16 pound baby was born in Texas to a mother with gestational diabetes. Can you explain what happens with the mother and the baby when the mother has gestational diabetes?
Dr. Jagasia: Gestational diabetes is a condition where a woman is diagnosed with diabetes for the first time during pregnancy. Gestational diabetes is often not treated as seriously as it should be only because it is often a transient condition during pregnancy.
Poor control of blood sugars during pregnancy can cause increased complications for both the baby and mother. As in this case, the baby can gain excessive body weight, which can increase the baby`s chance of requiring cesarean section for delivery and can also increase complications after birth, which can increase the newborns chances of admission neonatal intensive care units. These babies can also subsequently be at a much higher risk of developing adult obesity and health problems associated with that. Women with poorly controlled gestational diabetes and high risk of developing preeclampsia or blood pressure elevations in the in pregnancy and of requiring cesarean sections, as mentioned above.
Women who developed gestational diabetes usually have an underlying tendency towards diabetes , which in a way gets unmasked during pregnancy, related to weight gain and reduced efficiency of her bodies insulin to lower blood sugars, in the setting of secretion of several placental hormones , which reduce the bodies insulin efficiency.
DiabetesCare.net: Why is it that babies of mothers with gestational diabetes can be quite large at birth?
Dr. Jagasia: In women with gestational diabetes, the mothers higher blood sugars go across the placenta from the mother to the baby. This causes that the baby’s pancreas to produce more insulin to normalize his or her blood sugars. The higher insulin has a tendency to cause more weight gain. Also, recent research has suggested that these babies have a tendency to gain weight as adolescents and adults and are at a higher risk of developing diabetes or other complications of excessive weight gain and obesity, such as, high cholesterol and blood pressure.
DiabetesCare.net: What is Vanderbilt’s newer protocol for screening pregnant women for gestational diabetes?
Dr. Jagasia: Universal screening for gestational diabetes is currently standard of care between 24 to 28 weeks of the pregnancy. We are currently studying alternative ways of diagnosing diabetes earlier in the pregnancy, if possible, in an effort to reduce complications to both mother and baby. We are studying the use of a test called HbA1c (hemoglobin A1c), which gives you an average blood sugar over the last 3 months, for this purpose. Based on this women who fall into higher risk categories, are screened for gestational diabetes sooner than the current standard care. We look forward to analyzing the results to decide on whether this is a reasonable step to continue with.
DiabetesCare.net: One of your specialties is treating patients who develop post-transplant diabetes. Can you provide an overview of what that is exactly and the more common pathways for developing it?
Dr. Jagasia: Vanderbilt is a large tertiary medical center, and it has various subspecialty transplant programs. Transplant patients are a special group of patients that can develop several metabolic complications post-transplant, such as a higher tendency towards diabetes. Stress of the underlying illness, steroid medications and immune suppressing medications used after transplant, can all increase the patient`s risk of developing diabetes. Higher blood sugars can increase the patient`s chances of developing infections, especially in the setting of having a suppressed immune system due to medications that are used after transplantation. In addition, these patients are at a higher risk of developing associated health problems such as blood pressure and cholesterol elevation, which in combination can increase the long-term risk of heart disease etc.
Originally posted by DiabetesCare.net on August 5, 2011.