XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Founded in 1961 to replace the Organisation for European Economic Cooperation (OEEC), which was linked to the Marshall Plan and was established in 1948. The change of title marks the Organisation’s altered status and functions: with the accession of Canada and USA as full members, it ceased to be a purely European body, and at the same time added development aid to the list of its priorities. The aims of the organization are to promote policies designed to achieve the highest sustainable economic growth and employment and a rising standard of living in Member countries, while maintaining financial stability, and thus to contribute to the development of the world economy; to contribute to sound economic expansion in Member as well as non-member countries in the process of economic development; and to contribute to the expansion of world trade on a multilateral, nondiscriminatory basis in accordance with international obligations.

Organization for Economic Co-Operation and Development (OECD)

genannte norwegische Anthropotoge HALFDaN B~Y~ ha t in ether 1928 erschienenen Schrift (Die K6rperproportionen des Homo caesius. I~gl. Norsk. Vidensk. Selsk. Skr. z927, Nr 6, 273--356 ) die Variationsbreite der nordischen IRasse (Homo caesius) zu bes t immen gesucht, indem er 8I Individuen aus ether gr6f3eren Serie yon Miinnern ausw~hlte, die der norwegischen binnenl~ndischen Bev61kerurlg aJagehOren. Obwohl sie nach ihm eine ziemlich nngleichartige Masse darstellen mit hoher und Meiner K6rpergrOBe, mit t taar und Augenfarben in allen Nuancen mit Ausnahme der dunkelsten, mit ether Kopfform, die yon Dolichocephalie his welt in die Brachycephalie hineinreicbt, rechnet sie BRYN doch alle zur nordischen Rasse, Man k6nne n~imlich unter keinen Umst~nden behaupten, dab diese ,,kleinen Unterschiede\" auf Rassenmischungen beruhten; es set nicht angXngig, einem Ind iv iduum die Zugeh6rigkeit zur nordischen Rasse abzusprechen, well es brachycephal oder breitgesichtig set, ebensowenig wie zwei Sch~idel zu verschiedenen Rassen geh6ren mfiBten, well der eine dolichocephal und schmalgesichtig und der andere brachycephal und breitgesichtig ist. An diese Auffassung, die den Rassebegriff sehr vim wetter faBt, als es im allgemeinen in der Anthropologie iiblich ist, und in den meisten Darstel lungen zum Ausdruck kommt , wird man erinnert, wenn man das ]3ueh WALTER IKRUSES liest (Die Deutschen und ihre Nachbarv61ker. Neue Grundlegung der Anthropologie, l~assen-, Vblker-, S tammeskunde und t(onst i tut ionslehre nebst Ausf~hrungen zur deutschen Rassenhygiene. Leipzig: GeorgThieme 1929. Mit 17 Textabb. und 5 Tat., XIV, 640 S,). BRYN h~ilt an dem Rassebegriff test, wenn er zweifellos anch die Rassegrenzen verwischt. K~USE ist radikaler, er spricht zwar yon der ,,europ~iischen Rasse\", 16st sie abet n icht in eigentliche Unterrassen ant, sondern in V61ker. Das Volk nnd nicht die !~asse ist also hier die Grundlage ether anthropologischen VVertung, und diese Subst i tut ion meint er woht, wenn er yon ether neuen Grundlegung der Anthropologie spricht. Ffir KRUSE ist weder die K6rpergrbBe noch die Kopfform Rassenmerkmal , weil sie in weiten Grenzen schwa~kten nnd in ihren MaBen yon XuBeren Verhltltnissen hochgradig abhXngig seien. Nnr die P igment ie rnng yon Haut , Haa r nnd Auge sieht er Ms verh~iltnism~iBig besti~ndig an, wenn er auch ein Mendeln nnr ftir die Augenfarben anerkennen wi l l Die Vigment ierung t r e t e nnabhXngig yon alien fibrigen Merkmalen auf nnd stfinde in engster Beziehung zn der geographisehen Lage, d. h. znm ~Iima. KR~Js~ stii tzt Mch bet diesen Aufstellungen zum TeiI auf die vorliegende Literatnr, zum Teit auf eigene Erhebungen an etwa ~oooo Personen aus fas t allen Teilen Dentschlands. Altein dieses eigene Material wird nicht so geboten, wie es in anthropoIogischen Arbeiten sonst iiblich ist, so dab es schwer f~illt, sich ein Urteil fiber die Zuverl~issigkeit nnd I)eutbarkei t in der yon dem Verfasser gesuchten Rich tung zu bilden. Es ist fiberall in Raisonnements eingeschlossen, die f iberhaupt ein Charakter is t ikum des Buches sind. Wenn, n m nu t ein Beispiel anzuffihren, behaupte t wird, dab die Kopfform der Neugeborenen in allen Teilen Deutschlands, ob sie nun aus Gebieten einer langk6pfigen oder kurzk6pfigen Bev61kerung s tammen, nahezu die gleiche -mesocephale -w~ire, so bedarf das trotz der angeffihrten Zahlen ether sehr sorgfMtigen NachprtKung, obwohl, selbst wenn dem so w~re, daraus nieht ohne weiteres auf die Belanglosigkeit der Kopfform f~ir die 1Rassenbestimmung geschlossen werden kann. Die Ausfi ihrungen KRUs~s kommen ihrem Kern Anthropologische Mitteitungen. zz9

Das Arteriensystem der Japaner

How to investigate drug use in health facilities : selected drug use indicators

Ramanan Laxminarayan and Ranjit Roy Chaudhury examine the factors encouraging the emergence of antibiotic resistance in India, the implications nationally and internationally, and what might be done to help.

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Antibiotic Resistance in India: Drivers and Opportunities for Action.

Aims: The aim was to study morphometry, site of umbilical cord insertion and histological changes in placentae of women with gestational diabetes mellitus and compare the results with those of normal pregnancies and observe the perinatal outcome. Methods: It was an observational, correlational study of 130 placenta specimens collected from labour room and operation theatre of Department of Gynaecology & Obstetrics, Institute of Post Graduate Medical Education and Research, Kolkata. The subjects were mothers who attended antenatal clinic of the hospital regularly and delivered their babies in the same hospital. Cases were selected randomly, and divided in two groups: group A consisted of mothers having normal, uncomplicated pregnancy, group B consisted of mothers whose pregnancies were complicated by gestational diabetes mellitus. Morphometry, site of umbilical cord insertion and histological changes in placentae of all women were recorded. Perinatal outcome of the cases were also registered. The statistical methods used were chi-square test and Mann-Whitney U test. Results: It was observed that the placentae of diabetic mothers were significantly bigger in size, weight, volume, area, thickness, diameter and circumference than those of normal mothers. Also, in diabetic mothers, there was significant increase in villous oedema, fibrin deposition, calcification and congestion of blood vessels. These placental changes were significantly correlated with birth weights of babies. Out of 70 mothers in Group B, 65 had live births, 5 had still-born babies. Conclusions: Placentae of women with GDM showed several changes that may be associated with impaired functioning, leading to bad perinatal outcome.

Histologic and morphometric study of human placenta in gestational diabetes mellitus

Adjunct therapy of Ayurvedic medicine with anti tubercular drugs on the therapeutic management of pulmonary tuberculosis.

Background: The greatest disadvantage in the presently available potent synthetic anti‑inflammatory drugs lies in their toxicity and reappearance of symptoms after discontinuation. Hence, people are returning to the natural products with the hope of safety and security. Several species of Mikania have been reported to have anti‑inflammatory properties. Aim: The present study aims to assess the anti‑inflammatory activity of the ethanolic extract of the leaves and stem of Mikania scandens in vivo and in vitro . Materials and Methods: The in vitro bioassay consisted of assaying the effect of the extracts against denaturation of protein (egg albumin) and measuring the absorbance. In vivo anti‑inflammatory activity was checked by measuring the percentage inhibition of carrageenan‑induced rat paw edema after oral administration of the extracts to male Wistar rats. Results: The plant extracts revealed the presence of tannins, alkaloids, steroids and flavonoids in both the leaf and stem extracts. The in vitro study of leaf extracts of M. scandens demonstrated that at 16000 μg/ml concentration a better anti‑inflammatory activity was exhibited which is more than the stem extracts. Similarly in the in vivo study, carrageenan induced inflammation was significantly antagonized by M. scandens leaf extract, with inhibition of 50% at 1000 mg/kg. Conclusion: The ethanolic extract of both leaf and stem of M. scandens showed potent anti‑inflammatory activity. In comparison the leaf extract found to be more potent in both the conditions in vivo and in vitro, comparing with the standard drug diclofenac sodium and traditional control rumalaya perhaps due to the presence of phytochemicals like alkaloids and flavonoids in the plant. Keywords: Anti‑inflammatory, Mikania scandens (L.) wild, Phytochemicals

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Evaluation of Phytochemical Screening and Anti Inflammatory Activity of Leaves and Stem of Mikania scandens (L.) Wild.

Objective: To examine the frequency of proper use of inhalation devices and influence of age and training on it.

Materials and Methods: One hundred and five subjects of bronchial asthma and Chronic Obstructive Pulmonary Disease (COPD); aged between 18 to 75 y (mean ± SD; 46 ± 28.55) were studied. Subjects were enrolled over a period of three months. Data like weight, height and concomitant medications were recorded. It was an observational and questionnaire based study. Parameters were chosen to demonstrate the inhalational technique, errors committed in different steps of use & nature of medical, paramedical, nursing personals and others imparting training for use of inhaler device and time devoted for it.

Results: Of total 105 patients, 31 were using dry powdered inhalers (DPI), 50 on metered dose inhalers (MDI), and 24 on MDI with spacer devices. Among study population 83.81% were trained by healthcare professionals (doctors, nurse, pharmacists, paramedical or representatives of Pharmaceutical companies) and 16.19% are trained by general people. Among the MDI users (n=50) only 6%, 16.12% among the DPI users, 20.8%, among MDI with spacer users could use inhalers correctly. At 95% confidence limit there was significance of errors committed between DPI and MDI users (difference of SE is 2.56) and between spacer and MDI users (difference of SE 2.92). There was no difference found in regard of frequency of errors committed in taking different devices according to patient’s socioeconomic, educational background and trainer.

Conclusion: It was concluded that use of MDI with spacer most convenient method. Doctors often did not have sufficient time to train patients regarding proper technique of inhaler use. With ever increasing and widespread use of inhalers patients’ education is becoming more important. Proper training will surely make these drugs more effective and cost benefit ratio more favourable.

Study of Proper use of Inhalational Devices by Bronchial Asthma or COPD Patients Attending a Tertiary Care Hospital

Obturator artery is a medium-calibre parietal branch of internal iliac artery having wide variations in its origin. Since there was no previous investigation of variations of origin of obturator artery in a large series of eastern Indian subjects, it was decided to undertake this study. 56 pelvic halves from formaldehyde preserved cadavers were dissected in Calcutta National Medical College, Kolkata and B.S. Medical College, Bankura over a period of 3 years. Obturator artery originated in maximum number (44.6%) of cases from the anterior division of the internal iliac artery, the next common site (23.2%) being the inferior epigastric artery. Relatively late appearance of the obturator artery amongst the branches of internal iliac artery is most likely to be the cause of such a wide variation.

Anjan Adhikari

Papers

Histologic and morphometric study of human placenta in gestational diabetes mellitus

Adjunct therapy of Ayurvedic medicine with anti tubercular drugs on the therapeutic management of pulmonary tuberculosis.

Evaluation of Phytochemical Screening and Anti Inflammatory Activity of Leaves and Stem of Mikania scandens (L.) Wild.

Study of Proper use of Inhalational Devices by Bronchial Asthma or COPD Patients Attending a Tertiary Care Hospital

Variation of Origin of Obturator Artery in Eastern Indian Population - A Study