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

Comment on "metabolic syndrome and elevated C-reactive protein levels in elderly patients with newly diagnosed depression".

/pdf/gorme-ve-kas-gucu-kaybi-ile-gelen-bir-poems-sendromu-olgusu-166u3klxuj.pdf

Görme ve Kas Gücü Kaybı ile Gelen Bir POEMS Sendromu Olgusu

Effect of a hypocaloric diet on serum visfatin in obese non-diabetic patients

In a recent article in the Journal of Oral Rehabilitation, Miyashita and colleagues suggested the usefulness of measuring the amount of laryngeal upward movement and pharyngeal area by the videofluoroscopic swallowing study to determine decreased swallowing muscle function in sarcopenia (1). Although a small number of patients were included making it hard to perform extensive multivariable analyses and to draw firm conclusions, the study suggests a novel, single procedure to diagnose sarcopenic dysphagia.

Amount of laryngeal upward movement and pharyngeal area as indicators of decreased swallowing muscle function in sarcopenia.

We read with interest the article by Al-Thani et al. [1] reporting a very low frequency (2.6%) of peripheral arterial disease (PAD) in people with acute coronary syndrome in a multicenter study conducted in six Middle Eastern countries. A recent multicenter study in Turkey showed 20% prevalence of PAD in people with established cardiovascular disease or who were at risk for atherosclerotic diseases [2].

Diabetes that was present in 70% of the participants in their study is actually a major cause of arterial stiffness or calcification, which frequently results in misclassification of diabetics in ankle brachial index (ABI) testing by causing paradoxically high values [3]. In this context, it would be utmost helpful if the authors could provide some data related to the prevalence of a high ABI (>1.4) in their study population, so that the readers could recognize whether a high ABI potentially influenced the frequency of a low ABI.

Another point that should be noted is the method of assessment of PAD by ABI testing. In recent years, many societies published detailed consensus guidelines on the definition and management of PAD [4–6]. Collectively, the ABI cut-off value for the diagnosis of PAD is currently accepted as ≤0.9. Although ABI of <0.8 can be found in several surveys as the diagnostic threshold, adherence to guidelines and their updates would be a superior evidence-based approach. In such case, it could be speculated that the prevalence of PAD would be recorded some higher in the study by Al-Thani et al.

A final concern is the need for a correct calculation of ABI. As explained clearly in the TASC II guidelines, [4] higher readings of dorsalis pedis or tibialis posterior arteries should be used as the numerator in the index formula. However, Al-Thani et al. used the average (i.e., mean of dorsalis pedis plus tibialis posterior records) systolic blood pressure readings in each ankle as the numerator in order to calculate the ABI ratio. Compared to guideline recommendations, this method obviously results in use of lower values for any ankle especially when one of the readings is lower than the other, causing an increase in the frequency of a low ABI. Opposite to our concern regarding the ABI cut-off in the previous section, such a calculation could further reduce the reported prevalence of PAD in this multicenter large scale survey. However, through a scientific view, this does not eliminate the potential limitations. We guess that the readers would appreciate if the authors could comment on these issues.

https://downloads.hindawi.com/journals/ijvm/2012/409057.pdf

Ilker Tasci

Papers

Comment on "metabolic syndrome and elevated C-reactive protein levels in elderly patients with newly diagnosed depression".

Görme ve Kas Gücü Kaybı ile Gelen Bir POEMS Sendromu Olgusu

Effect of a hypocaloric diet on serum visfatin in obese non-diabetic patients

Amount of laryngeal upward movement and pharyngeal area as indicators of decreased swallowing muscle function in sarcopenia.

Very Low Frequency of PAD in People with CHD in Six Middle Eastern Countries