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.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(08)60074-4.pdf

Epidemiology and causes of preterm birth

Methods: We conducted a systematic review of studies published from January 1, 1950, through November 31, 2008, using PubMed, EMBASE, Web of Knowledge, CINAHL, and all Evidence-Based Medicine Reviews. Randomized clinical trials and prospective studies of RRTs that reported data on changes in the primary outcome of hospital mortality or the secondary outcome of cardiopulmonary arrest cases were included.

/pdf/a-systematic-review-and-meta-analysis-32tp0h3hqr.pdf

A Systematic Review and Meta-analysis

1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

Hyperglycemia and Adverse Pregnancy Outcomes

The implantation of fertilized ova and the formation of the placenta are crucial steps in reproduction. This review summarizes current information about these steps, including some of the molecular mechanisms that mediate them and how they may go awry, with consequent loss of the pregnancy.

Implantation and the survival of early pregnancy.

Labor is the physiologic process by which a fetus is expelled from the uterus to the outside world. Labor is defined as an increase in myometrial activity or, more precisely, a switch in the pattern of myometrial contractility from irregular contractures (long-lasting, low-frequency activity) to regular contractions (high-intensity, high-frequency activity),1 resulting in effacement and dilatation of the uterine cervix. In normal labor, there appears to be a time-dependent relation between the biochemical changes in the connective tissue in the cervix that usually precede uterine contractions and cervical dilatation. All these events usually occur before the spontaneous rupture of the fetal . . .

The control of labor.

Normal implantation and placentation is critical for pregnancy success Many pregnancy-related complications that present late in gestation (such as pre-eclampsia and preterm labour) appear to have their origins early in pregnancy with abnormalities in implantation and placental development Implantation is characterized by invasion of the maternal tissues of the uterus by fetal trophoblast, and the degree to which trophoblast invades these tissues appears to be a major determinant of pregnancy outcome Excessive invasion can lead to abnormally firm attachment of the placenta to the myometrium (placenta accreta) with increased maternal and perinatal morbidity Inadequate invasion, specifically restricted endovascular invasion, has been implicated in the pathophysiology of such conditions as pre-eclampsia (gestational proteinuric hypertension), preterm premature rupture of membranes, preterm labour, and intrauterine growth restriction The molecular and cellular mechanisms responsible for implantation remain enigmatic This review will include an overview of implantation followed by a discussion of a number of molecular mechanisms implicated in defective implantation and placentation including the role of decidual prostaglandins and haemorrhage in regulating trophoblast invasion An improved understanding of the molecular mechanisms responsible for abnormal implantation and placentation will likely improve clinicians' abilities to treat disorders that occur along this continuum, including infertility, recurrent pregnancy loss, pre-eclampsia, and preterm birth

https://www.rbmojournal.com/article/S1472-6483(10)60649-9/pdf

Defective implantation and placentation : laying the blueprint for pregnancy complications

Spontaneous rupture of membranes (ROM) is a normal component of labor and delivery. Premature ROM (PROM) refers to rupture of the fetal membranes prior to the onset of labor irrespective of gestational age. Once the membranes rupture, delivery is recommended when the risk of ascending infection outweighs the risk of prematurity. When PROM occurs at term, labor typically ensues spontaneously or is induced within 12 to 24 hours. The management of pregnancies complicated by preterm PROM (defined as PROM occurring prior to 37 weeks of gestation) is more challenging. Preterm PROM complicates 2% to 20% of all deliveries and is associated with 18% to 20% of perinatal deaths. Management options include admission to hospital, amniocentesis to exclude intra-amniotic infection, and administration of antenatal corticosteroids and broad-spectrum antibiotics, if indicated. This article reviews in detail the contemporary diagnosis and management of preterm PROM.

Errol R. Norwitz

Papers

Implantation and the survival of early pregnancy.

The control of labor.

Defective implantation and placentation : laying the blueprint for pregnancy complications

Contemporary Diagnosis and Management of Preterm Premature Rupture of Membranes

Impact of a comprehensive patient safety strategy on obstetric adverse events