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

https://www.onlinelibrary.wiley.com/doi/epdf/10.1111/j.1538-7836.2006.01753.x

International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS).

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Endothelial Cells in Physiology and in the Pathophysiology of Vascular Disorders

von Willebrand factor (VWF) forms high-molecular-weight multimers and plays an essential role in hemostasis, and thus its deficiency leads to bleeding symptoms. Acquired von Willebrand syndrome (AVWS) is rare, but potentially underdiagnosed, and develops in various underlying disorders. AVWS caused by anti-VWF autoantibodies is a rare subcategory of AVWS that can also be referred to as autoimmune VWF deficiency (AiVWFD). We performed a search of patients with autoimmune coagulation factor deficiencies in our nationwide survey in Japan. Among these, suspected cases of AiVWFD were extremely few, with only 11 case consultations in the last 10 years. Of these, three and five were respectively positive for anti-VWF autoantibodies (anti-VWF-Ab) and VWF inhibitor (VWF-inh). We also performed an extensive literature search of other cases from Japan, and in total, 40 cases were finally identified to have AiVWFD, with mean age of 55.0 years. Most underlying disorders were lympho- or myeloproliferative diseases, followed by autoimmune diseases. The major bleeding sites were subcutaneous and mucosal, the bleeding severity was moderate, and there were no hemorrhagic deaths. Bleeding time was prolonged; factor VIII activity, VWF antigen, and VWF activity were decreased, and high-molecular-weight VWF multimers were absent or decreased. These are similar to the common abnormal laboratory findings observed among general AVWS cases. Hemostatic therapy often involved VWF concentrates and vasopressin, and antibody eradication therapy often included corticosteroids and achieved remission. Notably, of all cases, 68% had anti-VWF-Abs, and 83% of anti-VWF-Ab-positive patients were also VWF-inh positive. To accumulate precise clinical information on AiVWFD, it is necessary to verify and improve the measurement methods for both anti-VWF-Ab and anti-VWF-inh. These findings from Japan should be confirmed in other geographic localities.

A Review of Autoimmune Acquired von Willebrand Factor Deficiency in Japan.

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2020 Eberhard F. Mammen Award Announcements: Part II-Young Investigator Awards.

von Willebrand disease (VWD) is reportedly the most common inherited bleeding disorder, and can also arise as an acquired (von Willebrand) syndrome (AVWS). The hemostasis laboratory plays a key role in the diagnosis or exclusion of VWD/AVWS, which may otherwise be suspected due to the patient's clinical (bleeding) history. VWD/AVWS arise from deficiency and/or defects in the adhesive plasma protein, von Willebrand factor (VWF). VWF undertakes various roles within hemostasis, but principally acts within primary hemostasis to anchor platelets to sites of vascular damage, thereby facilitating thrombus formation to arrest bleeding. The diagnosis or exclusion of VWD/AVWS requires laboratory testing for both VWF level and activity, with the latter potentially comprising several of a potential plethora of different assays. Complete diagnosis of VWD also requires the differentiation of VWD type, with six types comprising the current classification (i.e., qualitative [types 2A, 2B, 2M, 2N VWD] vs. quantitative [types 1 and 3 VWD] deficiency/defects). Although appropriate diagnosis and type classification hold important therapeutic consequences, these remain problematic and sometimes elusive for some laboratories to achieve. This report reviews the laboratory aided diagnosis or exclusion of VWD from a geographic perspective, and focuses on the disparities of approaches and methods in different regions of the world. This is primarily done from the perspective of data available from published reports related to external quality assessment (or proficiency testing) from different geographic localities. Moreover, differences in approaches between laboratories may arise due to differential adherence of particular guidelines, as well as regulatory aspects and predominance of local manufacturers and suppliers.

Laboratory Diagnosis of von Willebrand Disease (VWD): Geographical Perspectives.

Welcome to the latest of our Eberhard F Mammen award announcements. As noted previously,1–3 Thieme, the publisher of Seminars in Thrombosis & Hemostasis (STH), has created the Eberhard FMammen Excellence in Thrombosis and Hemostasis Awards in honor of Eberhard Mammen (►Fig. 1) and in recognition of his contribution to this field and to the journal that he both founded and steered formore than three decades. These awards began in 2009, under two categories, “Most Popular Article Awards” and “Young Investigator Awards.” Current details and conditions of the award can be summarized as follows:

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2015 Eberhard F. Mammen Award Announcements: Part I--Most Popular Articles.

The letter referring to our article1 on the effect of electronic cigarettes (e-cigarette) on human health by Farsalinos et al is both interesting and of value.2 The authors basically argue against two issues that we discussed in our previous narrative review, that is, the cardiovascular risk attributable to nicotine and the effective toxicity of liquid nicotine present in e-cigarettes. Besides the fact that the biological evidence available on e-cigarette smoking remains to date rather limited, some aspects need to be highlighted. As regard the effect of nicotine on cardiovascular risk, two of the articles used by Farsalinos et al2 in support of a lack of plausible connection are fairly dated, being respectively published in 1996 and 1998.3,4 A more recent metaanalysis on smokeless tobacco and risk of myocardial infarction and stroke published by Boffetta and Straif in 2009 concluded that the relative risk for ever use of smokeless tobacco products was 1.13 (95% confidence interval [95% CI], 1.06–1.21) for myocardial infarction and 1.40 (95% CI, 1.28–1.54) for fatal stroke.5 Also, at variance with what is stated in their correspondence,2 data about the cardiovascular potential of nicotine are contradictory. Besides episodic case reports of patients developing acute myocardial infarction while using nicotine patches,6,7 additional population studies described a high rate of cardiovascular complications in patients using these sticking plasters.8,9 Even from a biological perspective, the statement that nicotine has minimal effects in initiating and propagating atherosclerosis is questionable, as recent studies have shown that this compound binds to nicotinic acetylcholine receptors and accelerates the atherogenic process.10 Therefore, although we would agree that nicotine replacement therapies (NRTs) present a lesser hazard than continuing to smoke because there exists unquestionable data supporting that use of NRTs carries much lower risks than traditional tobacco smoking, our leading concern relates to the potential health effects of these devices on adolescent and nonsmokers.11 After decades of effective work to reduce cigarette smoking, the widespread availability of e-cigarettes raises the question of whether these devices are reintroducing a form of smoking to many adolescents, who may respond positively to advertising claims that e-cigarettes are safe.12 Once accustomed to e-cigarettes use, they may then be subjected to adverse side effects of these devices or, even worse, prompted to shift to traditional tobacco smoking. We also dispute the statement by the authors2 that we have exaggerated the toxicity of liquid nicotine present in ecigarettes. The number of case reports regarding toxicity of nicotine-containing solutions is constantly growing in the scientific literature.13–16 Moreover, a recent study investigating the nicotine concentration of several nicotine-containing solutions has concluded that these mixtures could be toxic or lethal if taken other than as directed, even at potentially lower levels of nicotine than expected using manufacturer specifications.17,18 In conclusion, although we respect the points of view raised by Farsalinos et al,2 at this point in time it seems premature and potentially hazardous to conclude that e-cigarette use and/or nicotine intake are unlikely to significantly elevate harm. Major caution should be observed until the outcome of randomized, perspective studies on e-cigarette use become available.

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Emmanuel J. Favaloro

Papers

A Review of Autoimmune Acquired von Willebrand Factor Deficiency in Japan.

2020 Eberhard F. Mammen Award Announcements: Part II-Young Investigator Awards.

Laboratory Diagnosis of von Willebrand Disease (VWD): Geographical Perspectives.

2015 Eberhard F. Mammen Award Announcements: Part I--Most Popular Articles.

Response to "Comment on 'E-cigarettes and cardiovascular risk: beyond science and mysticism'".