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

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

COVID-19 Dashboard

argument is often, if not acrimonious, at least heated. It gives an impression of the fluidity of opinion on many fundamental ideas under discussion and of the urgency with which cardiac cyanosis in the newborn is regarded. When Dr. William Muscott says that the earliest he has operated for pulmonary stenosis is on an infant 3 days old, and Sir Russell Brock agrees that the earlier in the first month that operation is undertaken the better, and when Dr. Varco asks Dr. Senning 'so far as I know they have never yet catheterized any child intrauterine in Sweden, but they have done it through the delivery canal sometimes-would you tell us the indications of the Scandinavian group for catheterization in the immediate newborn period?', one is indeed being kept up with the times. But that was two years ago and already some of the questions then debated have since been answered. This beautifully printed and well-illustrated stiff paperbacked volume is, and will for a few years yet remain, an invaluable companion to a full-scale textbook on congenital heart disease.

Growth at Adolescence.

Background Metformin is an oral anti-hyperglycemic agent that has been shown to reduce total mortality compared to other anti-hyperglycemic agents, in the treatment of type 2 diabetes mellitus. Metformin, however, is thought to increase the risk of lactic acidosis, and has been considered to be contraindicated in many chronic hypoxemic conditions that may be associated with lactic acidosis, such as cardiovascular, renal, hepatic and pulmonary disease, and advancing age. Objectives To assess the incidence of fatal and nonfatal lactic acidosis, and to evaluate blood lactate levels, for those on metformin treatment compared to placebo or non-metformin therapies. Search strategy A comprehensive search was performed of electronic databases to identify studies of metformin treatment. The search was augmented by scanning references of identified articles, and by contacting principal investigators. Selection criteria Prospective trials and observational cohort studies in patients with type 2 diabetes of least one month duration were included if they evaluated metformin, alone or in combination with other treatments, compared to placebo or any other glucose-lowering therapy. Data collection and analysis The incidence of fatal and nonfatal lactic acidosis was recorded as cases per patient-years, for metformin treatment and for non-metformin treatments. The upper limit for the true incidence of cases was calculated using Poisson statistics. In a second analysis lactate levels were measured as a net change from baseline or as mean treatment values (basal and stimulated by food or exercise) for treatment and comparison groups. The pooled results were recorded as a weighted mean difference (WMD) in mmol/L, using the fixed-effect model for continuous data. Main results Pooled data from 347 comparative trials and cohort studies revealed no cases of fatal or nonfatal lactic acidosis in 70,490 patient-years of metformin use or in 55,451 patients-years in the non-metformin group. Using Poisson statistics the upper limit for the true incidence of lactic acidosis per 100,000 patient-years was 4.3 cases in the metformin group and 5.4 cases in the non-metformin group. There was no difference in lactate levels, either as mean treatment levels or as a net change from baseline, for metformin compared to non-metformin therapies. Authors' conclusions There is no evidence from prospective comparative trials or from observational cohort studies that metformin is associated with an increased risk of lactic acidosis, or with increased levels of lactate, compared to other anti-hyperglycemic treatments.

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Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus

The coronavirus disease 2019 (COVID-19) outbreak in Turkey, caused by severe acute respiratory syndrome coronavirus-2, is a reflection of the global public health crisis, which was declared by the World Health Organization on March 11, 2020 (World Health Organization, 2020a). As the virus is highly contagious and can quickly spread among people, cases started to appear across the country in a short time. All age groups in the community are at risk of becoming infected with the COVID-19. However, older adults are predisposed to have a more severe disease due to comorbid situations, including hypertension, diabetes, coronary heart disease, chronic obstructive heart disease, and renal failure, which reduce vitality and resilience (Zhou et al., 2020). Age-related decline in physiological reserve and the altered innate immune system, called immunosenescence, increases the risk of severe infections in older adults (Weiskopf et al., 2009). But the knowledge obtained from the previous outbreaks or flu seasons could not explain the unexpectedly higher risk of death with the increasing number of chronic diseases of aged people.While no evidence-based treatment strategy exists presently, social distancing has been the primary measure to prevent the spread of the virus. In this situation, the COVID-19 outbreak may cause some mental health issues in older individuals with no mental illness, as well as recurrence of the disease in people with psychiatric illness and stress in both themselves and relatives. In response to this process, the changes in the delivery of mental health services have to meet the needs of older adults better worldwide. This paper focuses on Turkey’s fight against the COVID-19 pandemic, the problems in geropsychiatric care, and their solutions encountered during the period of social isolation of older adults. The precautions to be taken during the outbreak, which seems to have a dynamic process, may change rapidly. This challenge may continue until we have a coronavirus vaccine. Epidemiology The first confirmed case of COVID-19 infection was reported on March 10, 2020, much later than in many European countries (Turkish Ministry of Health, 2020a; World Health Organization, 2020b). The first report of death from COVID-19 came on March 17, 2020, when the total number of cases had reached 98 (Turkish Ministry of Health, 2020a). As of May 12, 141,475 confirmed cases and 3,894 deaths from COVID-19 reported by the Turkish Ministry of Health. The preliminary estimated mortality rate is 2.75%, which is lower than the estimated global average of 6.2% (Turkish Ministry of Health, 2020b; World Health Organization, 2020c). However, these numbers are calculated among the closed cases and are subject to change dynamically as the number of discharged individuals increase. Although the TurkishHealthMinister’s daily briefings have persistently addressed the disease as disproportionately severe in older people, information on confirmed cases anddeaths in different age groupswas still not available to the public as of May 12, 2020.

/pdf/coronavirus-2019-covid-19-outbreak-and-geropsychiatric-care-vmfxwbm9p2.pdf

Coronavirus 2019 (COVID-19) outbreak and geropsychiatric care for older adults: a view from Turkey.

PurposeVariability of ankle brachial index (ABI) measured by the same observer in the same individual on three different occasions was examined.Basic methodsA single morning ABI was initially deter...

Individual variations in ankle brachial index measurement among Turkish adults

Smoking is closely associated with insulin resistance, though the mechanism is not clear. Adiponectin, a novel anti-atherosclerotic and anti-inflammatory adipose tissue product, which is closely associated with insulin resistance, was reported to be low in smokers with cofactors for atherosclerosis. However, the effects of smoking on circulating adiponectin levels in otherwise healthy people are unknown. In this study, a case control design was implemented to search for the effect of smoking on plasma adiponectin and insulin sensitivities in healthy people. Sixty-four healthy male smokers, with no family history of hypertension and diabetes mellitus were compared with appropriate 36 age and body mass index matched controls. Both the patients and controls were the soldiers of a troop with regular daily physical activity. Plasma adiponectin, high sensitive C-reactive protein (hsCRP), insulin and lipid levels, and insulin sensitivity as assessed by homeostasis model assessment index (HOMA) of the smokers were measured and compared with those of the controls. The plasma adiponectin, hsCRP, insulin levels and HOMA indexes of the two groups were similar. These parameters were not affected by the amount of cigarettes per day. HDL-cholesterol levels were lower (p = 0.01) and systolic blood pressures were higher (p = 0.02) in the smokers. These results indicate that smoking may not affect plasma adiponectin and insulin levels in young and healthy men with high exercise capacity.

Adiponectin and insulin resistance in young and healthy smokers.

Acute pancreatitis (AP) is the inflammation of pancreas, usually a mild and self-limited process but not uncommonly complicated and severe, which leads to multiple organ dysfunctions. The reported annual incidence of AP has ranged from 4.9 to 73.5 per 100,000 worldwide.1 Severe AP (SAP) occurs in 15% to 20% of these patients and requires intensive approaches in critical care units with mortality rates as high as 30%.2–4 Cytokines and inflammatory mediators were accused for systemic manifestations of the disease; on the other hand, translocation of enteric bacteria is the most important cause of subsequent systemic events such as sepsis and related complications.5,6 Thus, preventive and therapeutic strategies on deteriorating AP should target both protection of mucosal integrity and modulation of inflammatory mediators.

Poly(ADP-ribose) polymerase (PARP) enzyme system, which was one of the targets of this study, is responsible for the control of cellular processes, such as DNA repair, mitochondrial functions, and programmed cell death. 3-Aminobenzamide (3-AB) is an inhibitor of PARP. Previous studies on experimental AP models by PARP inhibition (PARPi) showed significant decrease in pancreatic injury scores7 and disease severity index.8 Recent studies also showed that significant improvements achieved by PARPi at respect of pancreatic tissue histopathology scores (THSc),9 tissue oxidative stress parameter (TOSp) status,10 and bacterial translocation (Bact-Trans) rates.11

Hyperbaric oxygen (HBO) therapy also has been investigated in previous experimental studies that have significantly improved TOSp12 and apoptosis in SAP.13,14 Thereafter, more recent studies by HBO in AP indicated that enhanced inflammatory response,15 cytokines levels,16 TOSp, and THSc.17,18

In consideration of previous studies, that PARPi or HBO has showed favorable effects, the objective of the present study was to evaluate effects of HBO and 3-AB cotreatment in SAP, at respect of Bact-Trans, THSc, and TOSp.

/pdf/a-new-combination-therapy-in-severe-acute-pancreatitis-2zjctb8s60.pdf

A new combination therapy in severe acute pancreatitis--hyperbaric oxygen plus 3-aminobenzamide: an experimental study.

B AC K G R O U N D Metab olic syndrome (MS) has been assoc i ated with an inc r e ased risk of card io v a sc ular dis e ase and mort ality. Mean plat elet vol ume (MPV), an index of plat elet act iv at io n , has been shown to be inc r e ased in card iovascular and cerebrovascular dis e ase such as acute myoc a rd ial inf a r ct io n and acute isch emic stroke. The aim of this study was to i nv e st ig ate the rel at ion of MPV levels and MS. M ET H O D S A total of 868 adult individuals (mean age of 45.4±17.2) w ere enr o lled in the study. Subjects were grouped as MS (n= 461) and controls (n=407) acc o rding to the ATP III crit er ia. Four hundred sixty one subjects (53.1%) had t h r ee or more met ab olic fea t ures (38% in men and 62% in women). Two hundred thirty five subjects (27%) had high fasting gluc ose, 386 (44.5%) had elev ated bloo d pressure, 452 (52.1%) had high serum TG, 485 ( 55.9%) had low HDL chol e st erol, and 517 (59.6%) were obese. MPV levels were mea s ured along with the body mass index (BMI), blood press ure, lipids, gluc ose, plat elet mass and plat elet count levels. R E S U LT S MPV, platelet mass and plat elet counts did not differ acc o rding to metab olic comp onent counts. In add it ion, no c o rr el at ion was found betw een MPV and BMI, bloo d pressure, lipids, gluc ose, plat elet mass and plat elet cou n t levels. CO N C L U S I O N S In conclusion, this study with a considerably large population suggests that, though individual components of the disease seem to be associated with an increase in platelet size, MPV may not be an indicator of enhanced thrombotic activity in people with MS.

Ilker Tasci

Papers

Coronavirus 2019 (COVID-19) outbreak and geropsychiatric care for older adults: a view from Turkey.

Individual variations in ankle brachial index measurement among Turkish adults

Adiponectin and insulin resistance in young and healthy smokers.

A new combination therapy in severe acute pancreatitis--hyperbaric oxygen plus 3-aminobenzamide: an experimental study.

Mean Platelet Volume Levels in Metabolic Syndrome