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

Arnarson et al. reported in a recent issue that ingestion of 20 g of whey protein immediately after resistance exercise did not augment lean body mass, strength and physical function in elderly people. Lean body mass, strength and physical function are the most critical measures in the prevention, diagnosis and treatment of sarcopenia. The results of the present study are particularly important, as exponentially increase in the number of elderly persons in the new century requires a public health approach to prevent and treat sarcopenia, which has a potential to create epidemic of disability in the future. However, we needed to discuss some issues on daily calorie requirement of study population in the study by Arnarson et al. Physical activity is an important determinant of energy needs among elderly, but seems to be the most variable component. American Dietetic Association recommended adjusting daily calorie requirement among elderly according to the physical activity level. Moreover, Hunter et al. reported that resistant training increased the total energy expenditure in a group of elderly aged 61–77 years old. The study by Arnarson et al. had a study protocol included resistance exercise thrice weekly, inevitably resulting in a marked increase in daily calorie requirement. However, daily calorie intakes in whey protein and control groups were not increased during the course of the study. The benefits obtained by the intake of whey protein would possibly be more pronounced when adequate calorie was provided in the study population. CONFLICT OF INTEREST

Increasing physical activity requires increasing energy intake in elderly

Increase in health care costs due to aorta calcification and low ABI in older men.

Establishing exercise habit is important when assessing lean body mass in elderly.

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.22822

Orlistat for Overweight Subjects with Nonalcoholic Steatohepatitis

We aimed to investigate the effects of treatment with amlodipine and valsartan, on markers of bone remodeling in newly diagnosed hypertensive adults. Forty-three subjects with newly diagnosed were included in the study. Patients were also randomly divided into two groups, and each group received monotherapy with amlodipine or valsartan. Blood levels of bone turnover markers and osteoprotegerin (OPG) / receptor activator of nuclear factor-κB ligand (RANKL) / RANK system were measured. Amlodipine reduced sRANKL levels and sRANKL/OPG ratio more than valsartan, and this decrease was statistically signifi cant (p<0.001, p=0.002, respectively). Although blood OPG concentration did not change after treatment in both groups, sRANKL/OPG ratio decreased signifi cantly (p<0.001). Amlodipine also caused some reduction in CTx blood levels compared to valsartan. So we can suggest that amlodipine may be a better option than valsartan in patients with osteoporosis or terms of prevention of bone loss in hypertensive adults.

Influences of treatment with amlodipine and valsartan on bone turnover markers and OPG/RANKL/RANK system in newly diagnosed hypertensive adults; which is more beneficial?

Ilker Tasci

Papers

Increasing physical activity requires increasing energy intake in elderly

Increase in health care costs due to aorta calcification and low ABI in older men.

Establishing exercise habit is important when assessing lean body mass in elderly.

Orlistat for Overweight Subjects with Nonalcoholic Steatohepatitis

Influences of treatment with amlodipine and valsartan on bone turnover markers and OPG/RANKL/RANK system in newly diagnosed hypertensive adults; which is more beneficial?