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

Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S)

ContextAbout 5% of the US population is morbidly obese. This disease remains
largely refractory to diet and drug therapy, but generally responds well to
bariatric surgery.ObjectiveTo determine the impact of bariatric surgery on weight loss, operative
mortality outcome, and 4 obesity comorbidities (diabetes, hyperlipidemia,
hypertension, and obstructive sleep apnea).Data Sources and Study SelectionElectronic literature search of MEDLINE, Current Contents, and the Cochrane
Library databases plus manual reference checks of all articles on bariatric
surgery published in the English language between 1990 and 2003. Two levels
of screening were used on 2738 citations.Data ExtractionA total of 136 fully extracted studies, which included 91 overlapping
patient populations (kin studies), were included for a total of 22 094
patients. Nineteen percent of the patients were men and 72.6% were women,
with a mean age of 39 years (range, 16-64 years). Sex was not reported for
1537 patients (8%). The baseline mean body mass index for 16 944 patients
was 46.9 (range, 32.3-68.8).Data SynthesisA random effects model was used in the meta-analysis. The mean (95%
confidence interval) percentage of excess weight loss was 61.2% (58.1%-64.4%)
for all patients; 47.5% (40.7%-54.2%) for patients who underwent gastric banding;
61.6% (56.7%-66.5%), gastric bypass; 68.2% (61.5%-74.8%), gastroplasty; and
70.1% (66.3%-73.9%), biliopancreatic diversion or duodenal switch. Operative
mortality (≤30 days) in the extracted studies was 0.1% for the purely restrictive
procedures, 0.5% for gastric bypass, and 1.1% for biliopancreatic diversion
or duodenal switch. Diabetes was completely resolved in 76.8% of patients
and resolved or improved in 86.0%. Hyperlipidemia improved in 70% or more
of patients. Hypertension was resolved in 61.7% of patients and resolved or
improved in 78.5%. Obstructive sleep apnea was resolved in 85.7% of patients
and was resolved or improved in 83.6% of patients.ConclusionsEffective weight loss was achieved in morbidly obese patients after
undergoing bariatric surgery. A substantial majority of patients with diabetes,
hyperlipidemia, hypertension, and obstructive sleep apnea experienced complete
resolution or improvement.

https://jamanetwork.com/journals/jama/articlepdf/199587/JRV40082.pdf

Bariatric surgery: a systematic review and meta-analysis.

Context.—Observational studies have found lower rates of coronary heart disease
(CHD) in postmenopausal women who take estrogen than in women who do not,
but this potential benefit has not been confirmed in clinical trials.Objective.—To determine if estrogen plus progestin therapy alters the risk for
CHD events in postmenopausal women with established coronary disease.Design.—Randomized, blinded, placebo-controlled secondary prevention trial.Setting.—Outpatient and community settings at 20 US clinical centers.Participants.—A total of 2763 women with coronary disease, younger than 80 years,
and postmenopausal with an intact uterus. Mean age was 66.7 years.Intervention.—Either 0.625 mg of conjugated equine estrogens plus 2.5 mg of medroxyprogesterone
acetate in 1 tablet daily (n=1380) or a placebo of identical appearance (n=1383).
Follow-up averaged 4.1 years; 82% of those assigned to hormone treatment were
taking it at the end of 1 year, and 75% at the end of 3 years.Main Outcome Measures.—The primary outcome was the occurrence of nonfatal myocardial infarction
(MI) or CHD death. Secondary cardiovascular outcomes included coronary revascularization,
unstable angina, congestive heart failure, resuscitated cardiac arrest, stroke
or transient ischemic attack, and peripheral arterial disease. All-cause mortality
was also considered.Results.—Overall, there were no significant differences between groups in the
primary outcome or in any of the secondary cardiovascular outcomes: 172 women
in the hormone group and 176 women in the placebo group had MI or CHD death
(relative hazard [RH], 0.99; 95% confidence interval [CI], 0.80-1.22). The
lack of an overall effect occurred despite a net 11% lower low-density lipoprotein
cholesterol level and 10% higher high-density lipoprotein cholesterol level
in the hormone group compared with the placebo group (each P<.001). Within the overall null effect, there was a statistically
significant time trend, with more CHD events in the hormone group than in
the placebo group in year 1 and fewer in years 4 and 5. More women in the
hormone group than in the placebo group experienced venous thromboembolic
events (34 vs 12; RH, 2.89; 95% CI, 1.50-5.58) and gallbladder disease (84
vs 62; RH, 1.38; 95% CI, 1.00-1.92). There were no significant differences
in several other end points for which power was limited, including fracture,
cancer, and total mortality (131 vs 123 deaths; RH, 1.08; 95% CI, 0.84-1.38).Conclusions.—During an average follow-up of 4.1 years, treatment with oral conjugated
equine estrogen plus medroxyprogesterone acetate did not reduce the overall
rate of CHD events in postmenopausal women with established coronary disease.
The treatment did increase the rate of thromboembolic events and gallbladder
disease. Based on the finding of no overall cardiovascular benefit and a pattern
of early increase in risk of CHD events, we do not recommend starting this
treatment for the purpose of secondary prevention of CHD. However, given the
favorable pattern of CHD events after several years of therapy, it could be
appropriate for women already receiving this treatment to continue.

https://jamanetwork.com/journals/jama/articlepdf/187879/JOC80678.pdf

Randomized Trial of Estrogen Plus Progestin for Secondary Prevention of Coronary Heart Disease in Postmenopausal Women

The metabolic syndrome

An ascites shunt is described in the form of an implantable, anti-reflux, fluid displacement, compression pump-catheter system. The system includes a double chambered multi-micro-orifice ascites collection device, an anti-reflux, anti-backdiffusion tubular compression pump, and an anti-reflux, anti-backdiffusion, non-thrombogenic catheter, all connected in series by flexible tubing. The shunt is used to transfer fluid from the peritoneum to a blood vessel to prevent accumulation of fluid within the peritoneal cavity. The pump and intravascular catheter include check valve tips of particular design to prevent both reflux and diffusion of blood components into the system.

Compression pump-catheter

A surgical access system including an access port device. The port device has a port member, a plurality of blades, and an articulation mechanism. The blades are circumferentially arranged about a longitudinal axis of the port member to collectively define an access region. The articulation mechanism defines a pivot point along a length of each blade, and is operable to articulate the blades between collapsed and expanded states. The blade tips collectively define a diameter in the collapsed state that is less than that in the expanded state. The blades rotate about the corresponding pivot point, and the pivot points move longitudinally relative to the port member, in transitioning between the contracted and expanded states. Light source(s) can be integrated with the blades or separately provided to enhance surgical field visibility.

Micro-orifice surgical access system

ONE OF the most intriguing and challenging problems the surgeon encounters today is the management of the patient in whom a massive small-bowel resection has been carried out in the treatment of a variety of pathologic entities. When only 90 cm or less of small intestine remain in continuity various problems may arise. These include diarrhea, steatorrhea, fluid and electrolyte imbalance, hypocalcemia, hypomagnesemia, decreased absorption of fat and fat soluble vitamins, hypoglycemia, anemia, negative nitrogen balance, hypersecretion, and weight loss. Cachexia readily follows. 1-10 A variety of surgical procedures including the use of reversed segments of small bowel and small-bowel loops have been proposed to minimize the fluid, electrolyte and other losses. 11-14 Disenchantment with the long-term results of these procedures 15 has prompted us to reassess the role of dietary management, combined with vagotomy and pyloroplasty which may decrease both acid secretion and peristaltic activity and thus improve absorption.

Massive small-bowel resections. Operative and dietary management.

IN VIEW OF the generally accepted fact that atherosclerosis is related to the concentration of the circulating cholesterol, efforts to prevent, retard, arrest, or reverse the atherosclerotic process have been directed towards cholesterol reduction. There are basically three approaches to cholesterol lowering employed today: diet, drugs, and surgery. The diet most commonly used to achieve cholesterol reduction is a diet low in cholesterol, with a high ratio of polyunsaturated to saturated fats (P/S ratio). These general principles were derived from the observations of epidemiologists on the importance of dietary constituents in influencing the circulating cholesterol. 1-4 Kinsell et al 5 studied in a controlled experiment the cholesterol lowering effect of diets containing large amounts of unsaturated fats. Connor et al 6,7 and Grande et al 8 demonstrated the role of dietary cholesterol in influencing serum cholesterol. The paper of Green et al 9 on the use of fat-modified foods for

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=SURG&articleId=567368&pdfFileName=archsurg_97_2_017.pdf

Treatment of Hypercholesterolemia: Combined Dietary, Surgical, and Bile Salt-Binding Resin Therapy

This paper serves as an introduction to a symposium on “Surgical Treatment of Morbid Obesity.” It offers a brief historical review of the antecedents for and the operative interventions in this field of metabolic surgery. In essence, the procedures can be divided between jejunoileal operations and their derivatives, and gastric operations. The jejunoileal bypasses originated with end-to-end jejunoileostomy; deviated to end-to-side jejunocolic, jejunocecal, and finally jejunoileal bypasses; and returned to end-to-end jejunoileal bypasses with different lengths of functioning bowel and various sites for colonic drainage of the bypassed bowel. More recently, pancreatic-biliary-intestinal bypass operations have been proposed. The gastric operations can be separated into gastric bypasses with closure of the fundic pouch and anastomosis to a segment of small intestine; gastroplasty with separation of the stomach into a small upper pouch communicating via a limiting orifice to the remainder of the stomach; and gastric partitioning, the simplest variation of gastroplasty, consisting of a cross-stapling of the stomach with omission of several central staples. Finally, vagotomy alone has been advocated. We must conclude with the commentary that there is no optimal operation in this field, but that we need not apologize for an “85% cure rate.” What we must work toward in the future is the development of therapy based not on circumvention but on an understanding of the satiety factor.

Henry Buchwald

Papers

Compression pump-catheter

Micro-orifice surgical access system

Massive small-bowel resections. Operative and dietary management.

Treatment of Hypercholesterolemia: Combined Dietary, Surgical, and Bile Salt-Binding Resin Therapy

The history of metabolic surgery for morbid obesity and a commentary