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

The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017

This article presents an introduction to the Health Belief Model (HBM). The HBM states that the perception of a personal health behavior threat is influenced by at least three factors: general health values, interest and concern about health; specific beliefs about vulnerability to a particular health threat; and beliefs about the consequences of the health problem. Once an individual perceives a threat to his health and is simultaneously cued to action, if his perceived benefits outweighs his perceived costs, then the individual is most likely to undertake the recommended preventive health action. Key words: health promotion, health belief model, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, self-efficacy. Content available only in Romanian.

Health Belief Model

Estimates of global seasonal influenza-associated respiratory mortality: a modelling study

Background The incidence of pneumonia and pneumonia related hospitalizations still increasing in different European and American Countries. However, in western countries this increase is driven by secondary diagnoses, recurrent pneumonia episodes in elderly and among those with comorbidities. Given the high frequency of Streptococcus pneumoniae among all pneumonia, it is reasonable to expect that a wide use of pneumococcal vaccines would reduce the burden of pneumonia in the elderly due to a direct and indirect effect. In Portugal, pneumococcal vaccines are available since 1996: pneumococcal polysaccharide vaccine (PPSV23) in 1996; heptavalent conjugated pneumococcal vaccines (PCV7) in 2001; PCV10 in April 2009 and PCV13 in January 2010. PPSV23 and PCV13 are widely recommended for risk groups and elderly. PCV7 serotypes reduced from 31% in 1999–2003 to 11% in 2009–2011 in non-invasive pneumococcal pneumonia (PP), but no decreasing trend was observed for PCV13 and PPSV23 serotypes until 2011. Trends in pneumococcal pneumonia after PCV13 introduction are not known in Portugal. Thus, this study aims to assess population level impact of infant PCV13 introduction on burden of pneumonia among adults aged 65 or more in Portugal through comparison of trends in PP hospitalization rates before and after PCV13 introduction. Methods We performed an ecological study using hospital discharge registry data. Pneumococcal Pneumonia was defined as having a principal diagnosis coded as 481 (International Classification for Diseases - 9th version). To assess trends in hospitalization rates before (July 2003–June 2009) and after (July 2010–June 2016) PCV13 introduction interrupted time series analysis was used. Annual average change of pneumonia hospitalization rates was estimated by Poisson regression models adjusted for seasonality and allowing for over-depression. PP hospitalization rates estimated after immunization program introduction were compared with those projected based on pre-vaccination period trend. Bacterial pneumonia caused by pathogens other than S. pneumoniae was used for sensitivity analysis. Results At baseline, the overall PP hospitalization rate was 10.2/104. The rates varied markedly by age group, the highest baseline rates were observed among those aged 85 years or more, 38.6/104 in males and 23.4/104 in females. Statistically significant decline in overall PP hospitalization rate was verified during pre-PCV13 period, the rate decreased on average by 4.6% per year (IRR = 0.954; 95% CI: 0.943 to 0.964). The decreasing trend continued after PCV13 introduction, with more pronounced decline of 12.8% (IRR = 0.872; 95% CI: 0.858 to 0.886) per year. The decrease in PP hospitalizations was significant in all subgroups, the largest decline in both pre-PCV13 (5.8% per year) and PCV13 (14.3% per year) periods was verified for males aged 75–84. Smaller decrease was observed for Bacterial pneumonia after 2010 (IRR = 0.915; 95% CI: 0.913 to 0.937). Conclusions Using population-based nationwide registry data, we found considerable decrease in hospitalizations’ rates for PP in adults aged 65 or more years following infant PCV13 introduction in Portugal. Given the ecological design, we cannot exclude the effect of factors other than vaccination, namely changes in diagnosis and coding practices or the reduction of other pneumonia risk factors as tobacco, since decreasing trend was also observed for bacterial pneumonia after 2010.

Impact of 13-valent pneumococcal conjugate vaccination introduction in children on pneumonia hospitalizations among adults aged 65 or more in Portugal

Introduction and Objectives Hypertension is one of the main risk factors for disability and death from cardiovascular disease. Current guidelines include initiatives to control blood pressure in hypertensive patients that focus on lifestyle changes. The main objective of this study was to analyze the association between lifestyle and blood pressure in patients under antihypertensive medication. Methods Data collected in the Portuguese National Health Examination Survey (INSEF) were analyzed. Individuals who met INSEF inclusion criteria and reported being under antihypertensive medication in the two weeks prior to the questionnaire were studied. Lifestyle variables (alcohol consumption, smoking, added salt intake, fruit and vegetable consumption, and physical activity) were assessed by questionnaire, and systolic and diastolic blood pressure were measured by physical examination. Associations between lifestyle factors and blood pressure, stratified by gender and adjusted for sociodemographic variables and obesity, were estimated through a multiple linear regression model. Results Alcohol consumption (beta=6.31, p=0.007) and smoking (beta=4.72, p=0.018) were positively associated with systolic blood pressure in men. Added salt intake, fruit and vegetable consumption, and physical activity were not associated with blood pressure in men. In women, no association was observed for any behavioral variable. Conclusions These conclusions highlight the need in the population under antihypertensive medication, particularly in men, to focus on the fight against high systolic blood pressure in the two modifiable and preventable behaviors of smoking and alcohol consumption.

Effect of lifestyle on blood pressure in patients under antihypertensive medication: An analysis from the Portuguese Health Examination Survey.

Introduction: Health surveys constitute a relevant information source to access the population’s health status. Given that survey errors can significantly influence estimates and invalidate study findings, it is crucial that the fieldwork progress is closely monitored to ensure data quality. The objective of this study was to describe the fieldwork monitoring conducted during the first Portuguese National Health Examination Survey (INSEF) regarding protocol deviations and key performance indicators (KPI). Methods: Data derived from interviewer observation and from the statistical quality control of selected KPI were used to monitor the four components of the INSEF survey (recruitment, physical examination, blood collection and health questionnaire). Survey KPI included response rate, average time distribution for procedures, distribution of the last digit in a specific measure, proportion of haemolysed blood samples and missing values. Results: Interviewer observation identified deviations from the established protocols, which were promptly corrected. During fieldwork monitoring through KPI, upon implementation of corrective measures, the participation rate increased 2.5-fold, and a 4.4-fold decrease in non-adherence to standardized survey procedures was observed in the average time distribution for blood pressure measurement. The proportion of measurements with the terminal digit of 0 or 5 decreased to 19.6 and 16.5%, respectively, after the pilot study. The proportion of haemolysed samples was at baseline level, below 2.5%. Missing data issues were minimized by promptly communicating them to the interviewer, who could recontact the participant and fill in the missing information. Discussion/Conclusion: Although the majority of the deviations from the established protocol occurred during the first weeks of the fieldwork, our results emphasize the importance of continuous monitoring of survey KPI to ensure data quality throughout the survey.

/pdf/collecting-valid-and-reliable-data-fieldwork-monitoring-22lkx18j9j.pdf

Collecting Valid and Reliable Data: Fieldwork Monitoring Strategies in a Health Examination Survey

https://repositorio.insa.pt/bitstream/10400.18/227/1/Relat%c3%b3rio_vacina%20antigripal_2008-2009.pdf

Baltazar Nunes

Papers

Impact of 13-valent pneumococcal conjugate vaccination introduction in children on pneumonia hospitalizations among adults aged 65 or more in Portugal

Effect of lifestyle on blood pressure in patients under antihypertensive medication: An analysis from the Portuguese Health Examination Survey.

Collecting Valid and Reliable Data: Fieldwork Monitoring Strategies in a Health Examination Survey

Vacinação antigripal da população portuguesa, em 2008-2009: cobertura e algumas características do acto vacinal

Final report on the mortality from flu pandemic (H1N1) 2009 in Portugal (April 2009-August 2010)