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.

/pdf/risk-of-fatal-and-nonfatal-lactic-acidosis-with-metformin-4ujte07kg8.pdf

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

We read with interest the article by Rabkin et al who examined the relationship between ankle–brachial index (ABI) measurement and arterial stiffness in individuals without peripheral arterial disease (PAD). Although ABI was suggested as a marker of arterial stiffness, how to interpret a high ABI value, that is, above 1.4, is still not defined. Therefore, the study by Rabkin et al is important not only for documenting the predictive value of a high ABI for detecting arterial stiffness but also for being the first specifically designed investigation to test these possible relationships. Their results clearly show that an ABI value above 1.5 is indicative of arterial stiffness, which actually categorizes, according to European guidelines, an individual at high or very high risk, even in the absence of other cardiovascular risk factors. However, other than the 6 study limitations listed in the article, a major question is that inclusion and exclusion criteria were not provided in detail. An increased ABI is closely associated with long lasting diabetes mellitus which results in incompressible vessel wall, causing inappropriately high systolic blood pressure, which was detailed in the Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) II guidelines. In this context, while designing a study to test whether ABI measurement can be used to predict the presence of stiffened arteries, exclusion of diabetics specifically would be crucial in order to eliminate the possibility of getting falsely high ABI values that may indeed be markedly lower, even diagnostic for PAD. Moreover, recent data showed that several of PAD risk factors (eg, hypertension and smoking) are also associated with the presence of arterial stiffness. Therefore, we think that the readers would appreciate if the authors could comment on these issues and provide information about whether they excluded diabetic patients and whether their results were adjusted for other confounders (eg, age, smoking, hypertension, or dyslipidemia) so that the data can be used for better decision making.

https://journals.sagepub.com/doi/pdf/10.1177/0003319711417615

Ankle-brachial index as an indicator of arterial stiffness.

Coronavirus disease 2019 (COVID-19) related public health measures have promoted a radical change in the lifestyle of older people, reducing participation in community groups and social interaction.[1] Social isolation contributes to less physical activity and more sedentary behavior among older adults.[2] Disruption of physical activity in older patients who survived COVID-19 is also a potential issue. Therefore, we aimed to investigate whether older people with a history of COVID-19 have reduced physical activity compared to their life before infection.

Physical activity during the COVID-19 pandemic in older adults

Waist-to-hip ratio as an indicator of atherosclerosis among women at risk.

Risk of sarcopenia in hospitalized patients and related clinical factors: a multicenter study from Turkey

In a study published in this journal Wakabayashi & Sashika (1) report that a poor rehabilitation outcome for hospital-associated deconditioning in elderly patients is associated with nutritional state, chronic disease-related malnutrition and albumin levels. Hospital-associated deconditioning, described as functional decline related to acute hospitalization, is of particular relevance, as it has a high prevalence in elderly patients (approximately 30%). In addition, hospital-associated deconditioning increases the risk of institutionalization and death (2). In this context, we regard the current results as of particular importance in generating preventive strategies for hospital-associated deconditioning. We would like to comment on this study. In recent years, we have learnt that patient tolerance to physical or occupational therapy, cognition/ability to learn, motivation and mood are potential confounders in the outcome of rehabilitation programmes for hospital-associated deconditioning (2). Low mood, which commonly presents as depression in elderly patients, and impaired cognition may also adversely affect the dietary intake and nutritional state of this group of patients (3). However, Wakabayashi & Sashika’s study excluded subjects with deconditioning secondary to specific neurological insult, and did not report any screening or clinical evaluation results for the cognitive ability and mood of participants. We suggest that inclusion of these parameters would affect the multivariate analyses. Secondly, this study should focus on the daily calorie and protein intake of participants during the inpatient rehabilitation programme. Previous studies have shown that the protein and caloric intake of elderly and critically ill patients are frequently suboptimal during a period of hospitalization (4, 5). It has been reported in a meta-analysis that, in elderly subjects, adequate protein supplementation increases muscle mass and strength gains during prolonged resistance-type exercise training (6). The present study did not report adequate data on daily protein and calorie requirements and their management. Wakabayashi & Sashika’s study identifies relevant issues in the management of elderly inpatients; however, we suggest that future studies with a similar design should are required to address the above-mentioned methodological drawbacks.

Re: Malnutrition is associated with poor rehabilitation outcome in elderly inpatients with hospital-associated deconditioning: a prospective cohort study.

Ilker Tasci

Papers

Ankle-brachial index as an indicator of arterial stiffness.

Physical activity during the COVID-19 pandemic in older adults

Waist-to-hip ratio as an indicator of atherosclerosis among women at risk.

Risk of sarcopenia in hospitalized patients and related clinical factors: a multicenter study from Turkey

Re: Malnutrition is associated with poor rehabilitation outcome in elderly inpatients with hospital-associated deconditioning: a prospective cohort study.