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

Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment

Objective
To present the International Parkinson and Movement Disorder Society (MDS) Clinical Diagnostic Criteria for Parkinson9s disease.
Background
Although several diagnostic criteria for Parkinson9s disease have been proposed, none have been officially adopted by an official Parkinson society. Moreover, the commonest-used criteria, the UK brain bank, were created more than 25 years ago. In recognition of the lack of standard criteria, the MDS initiated a task force to design new diagnostic criteria for clinical Parkinson9s disease.
Methods/Results
The MDS-PD Criteria are intended for use in clinical research, but may also be used to guide clinical diagnosis. The benchmark is expert clinical diagnosis; the criteria aim to systematize the diagnostic process, to make it reproducible across centers and applicable by clinicians with less expertise. Although motor abnormalities remain central, there is increasing recognition of non-motor manifestations; these are incorporated into both the current criteria and particularly into separate criteria for prodromal PD. Similar to previous criteria, the MDS-PD Criteria retain motor parkinsonism as the core disease feature, defined as bradykinesia plus rest tremor and/or rigidity. Explicit instructions for defining these cardinal features are included. After documentation of parkinsonism, determination of PD as the cause of parkinsonism relies upon three categories of diagnostic features; absolute exclusion criteria (which rule out PD), red flags (which must be counterbalanced by additional supportive criteria to allow diagnosis of PD), and supportive criteria (positive features that increase confidence of PD diagnosis). Two levels of certainty are delineated: Clinically-established PD (maximizing specificity at the expense of reduced sensitivity), and Probable PD (which balances sensitivity and specificity).
Conclusion
The MDS criteria retain elements proven valuable in previous criteria and omit aspects that are no longer justified, thereby encapsulating diagnosis according to current knowledge. As understanding of PD expands, criteria will need continuous revision to accommodate these advances. Disclosure: Dr. Postuma has received personal compensation for activities with Roche Diagnostics Corporation and Biotie Therapies. Dr. Berg has received research support from Michael J. Fox Foundation, the Bundesministerium fur Bildung und Forschung (BMBF), the German Parkinson Association and Novartis GmbH.

MDS Clinical Diagnostic Criteria for Parkinson's Disease (S19.001)

Ductal carcinoma in situ (DCIS) of the breast represents a heterogeneous group of neoplastic lesions in the breast ducts. The goal for management of DCIS is to prevent the development of invasive breast cancer. This manuscript focuses on the NCCN Guidelines Panel recommendations for the workup, primary treatment, risk reduction strategies, and surveillance specific to DCIS.

https://www.unitypoint.org/desmoines/filesimages/Cancer%20Education/Oncology%20Nursing%20Conference/2015/2014%20NCCN%20Clin%20Pract%20Guidelines%20Male%20Sex%20Dysf.pdf

Clinical practice guidelines in oncology

Methods for Staging Non-small Cell Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Multimorbidity is one of the common clinical characteristics in older patients and its occurrence rises with age. With the increase of older population, physicians should know the clinical significance of multimorbidity in managing older patients. Multimorbidity focuses on the findings of multiple diseases in a single patient and interactions between diseases and a patient. It has been reported that the prevalence of multimorbidity is over 50% in elderly people and co-occurrence of certain chronic diseases is often observed in patients with multimorbidity. Multimorbidity is significantly associated with higher mortality, increased disability, impaired quality of life, and increased medical costs. Unfortunately, current guidelines do not address enough for older patients with multimorbidity. Simple and fragmented approach for multiple medical conditions in older patients may lead to many clinical problems including polypharmacy, iatrogenic events, and increased medical cost. Accordingly, comprehensive geriatric assessment and multidimensional approach for this population should be encouraged.

Multimorbidity in Older Adults

PURPOSE: The purpose of this study is to evaluate the outcome of low-dose whole brain radiotherapy (WBRT) with tumor bed boost after methotrexate-based chemotherapy in the management of primary central nervous system lymphoma (PCNSL). MATERIALS AND METHODS: We retrospectively analyzed 64 patients with pathologically proven PCNSL between 2000 and 2011. Methotrexate-based chemotherapy with a median of five cycles was followed by radiotherapy to the whole brain and to the initial tumor bed. The median dose to the whole brain and to the tumor bed was 27 Gy (range, 18 to 36 Gy) and 50.4 Gy (range, 45 to 54 Gy), respectively. RESULTS: With a median follow-up period of 27 months, 55 patients (85.9%) achieved complete response (CR). The 5-year overall survival (OS) and progression-free survival (PFS) rates were 52.6% and 39.3%, respectively. In univariate analysis, factors associated with OS were age, performance status, involvement of deep structure, and CR to sequential chemoradiotherapy (CRT). These variables remained as significant factors for OS in multivariate analysis. CR to sequential CRT was the only positive factor associated with PFS (p=0.009). Neurologic toxicity was more common in elderly patients older than 60 years (p=0.025). CONCLUSION: Low-dose WBRT with tumor bed boost after methotrexate-based chemotherapy might be an effective method for management of PCNSL.

/pdf/low-dose-whole-brain-radiotherapy-with-tumor-bed-boost-after-46g5z7e0vu.pdf

Low-Dose Whole Brain Radiotherapy with Tumor Bed Boost after Methotrexate-Based Chemotherapy for Primary Central Nervous System Lymphoma

Purpose This study was performed to assess the radiosurgical results of meningiomas extending into the internal acoustic canal (para-IAC meningiomas), with a particular focus on the effect of radiation dose to the cochlea on hearing outcome. Methods and Materials A total of 50 patients who underwent radiosurgery for para-IAC meningiomas between 1998 and 2009, which were followed for 2 years, were enrolled. The mean age was 55.8 years (range, 15–75). The mean tumor volume was 6.1 cm 3 (range, 1.0–19.0), the mean tumor length in the IAC was 6.9 mm (range, 1.3–13.3), and the mean prescribed marginal dose was 13.1 Gy (range, 10–15) at an isodose line of 50%. The mean follow-up duration was 46 months (range, 24–122). Results Eight (16.0%) patients had nonserviceable hearing at the time of surgery. At the last follow-up, the tumor control rate was 94%; unchanged in 17 patients, decreased in 30 patients, and increased in 3 patients. Among 42 patients with serviceable hearing at the time of radiosurgery, it was preserved in 41 (97.6%) patients at the last follow-up. The maximal and mean radiation doses to the cochleae of these 41 patients were 5.8 Gy ± 0.3 (range, 3.1–11.5) and 4.3 Gy ± 0.2 (range, 2.2–7.5), respectively. The maximal dose to the cochlea of the patient who lost hearing after radiosurgery was 4.7 Gy. Conclusions The radiation dose to the cochlea may have the minimal toxic effect on the hearing outcome in patients who undergo radiosurgery for para-IAC meningiomas.

Radiosurgery for para-IAC meningiomas: the effect of radiation dose to the cochlea on hearing outcome.

Background/Aims: A U-shaped relationship between body mass index (BMI) and mortality has been reported. However, controversy exists as to whether skeletal muscle mass affects mortality in healthy older adults. We evaluated the independent association of BMI or appendicular skeletal muscle mass (ASM) with mortality in elderly people. Methods: A total of 4,261 consecutive subjects older than 65 years who underwent health examinations at Seoul National University Gangnam Center between 2005 and 2009 were included in the analysis. ASM, ASM/height² and ASM/weight were estimated by bioelectrical impedance analysis. Sarcopenia was defined as a relative skeletal muscle mass of 1-2 SD below (class I) or more than 2 SD below (class II) the gender-specific mean for healthy young adults. BMI was grouped into five groups (A-E). Results: During the follow-up period (27.2 ± 13.5 months), 63 subjects died. The subjects who died were significantly older and had a male predominance, increased levels of inflammatory markers and poor nutritional statuses. In a fully adjusted Cox proportional hazards model, BMI was not associated with mortality. However, class I sarcopenia (HR 2.11, 95% CI 1.17 3.79) and class II sarcopenia (HR 3.47, 95% CI 1.62-7.43), defined by ASM/height², were related to all-cause mortality. This association was not observed when sarcopenia was defined by ASM/weight. Class II sarcopenia defined by ASM/height² was associated with cancer-related mortality (HR 5.73, 95% CI 2.22-14.78), but not with cardiovascular mortality (HR 1.56, 95% CI 0.17 14.27). Conclusions: This study indicates that lower skeletal muscle mass is a risk marker for cancer-related and all cause mortality in Korean elderly people. (Korean J Med 2013;85:167-173)

Skeletal Muscle Mass as a Predictor of Mortality in the Elderly Population

The authors present the experience of ligation of transverse or sigmoid sinus in the surgical removal of petroclival meningiomas. We reviewed the medical records and venograms of 14 patients with petroclival meningiomas, in whom the intraoperative ligation of transverse or sigmoid sinus had been done at our hospital between 1986 and 1999. All patients passed the intraoperative test clamping of the sinus. The drainage pattern of confluence of Herophili was classified into four types: type A, confluence and equal drainage on both transverse sinuses; type B, confluence and non-dominant transverse sinus on the tumor side; type C, confluence and dominant transverse sinus on the tumor side; and type D, unilateral transverse sinus only. Among the 14 cases, four cases were in type A, five cases in type B, and two were type C. There was no evidence of brain swelling after intraoperative test clamping of the sinus for more than 30 min. None of the patients experienced postoperative complications related with sinus ligation. Our observation suggests that the transverse or sigmoid sinus ligation is tolerable to patients who show the drainage patterns of type A, type B, and type C, if the test clamping proves to be safe.

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Hee-Won Jung

Papers

Multimorbidity in Older Adults

Low-Dose Whole Brain Radiotherapy with Tumor Bed Boost after Methotrexate-Based Chemotherapy for Primary Central Nervous System Lymphoma

Radiosurgery for para-IAC meningiomas: the effect of radiation dose to the cochlea on hearing outcome.

Skeletal Muscle Mass as a Predictor of Mortality in the Elderly Population

The experience of ligation of transverse or sigmoid sinus in surgery of large petroclival meningiomas.