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

Journal of Clinical NursingEarly View LETTER TO THE EDITOR Complexity of medication adherence among middle-aged and older adults (Comment on ‘Association between cognitive function and self-reported antihypertensive medication adherence among middle-aged and older hypertensive women’) Ilker Tasci MD, Corresponding Author Ilker Tasci MD Professor ilkertasci@yahoo.com orcid.org/0000-0002-0936-2476 Gulhane Faculty of Medicine & Training and Research Hospital, Department of Internal Medicine, University of Health Sciences Turkiye, Ankara, Turkey Correspondence Ilker Tasci, Gulhane Egitim ve Arastirma Hastanesi, Ic Hastaliklari Klinigi, Etlik 06018 Ankara, Turkey. Email: ilkertasci@yahoo.comSearch for more papers by this authorMehmet Ilkin Naharci MD, Mehmet Ilkin Naharci MD Professor Gulhane Faculty of Medicine & Training and Research Hospital, Department of Internal Medicine, University of Health Sciences Turkiye, Ankara, TurkeySearch for more papers by this author Ilker Tasci MD, Corresponding Author Ilker Tasci MD Professor ilkertasci@yahoo.com orcid.org/0000-0002-0936-2476 Gulhane Faculty of Medicine & Training and Research Hospital, Department of Internal Medicine, University of Health Sciences Turkiye, Ankara, Turkey Correspondence Ilker Tasci, Gulhane Egitim ve Arastirma Hastanesi, Ic Hastaliklari Klinigi, Etlik 06018 Ankara, Turkey. Email: ilkertasci@yahoo.comSearch for more papers by this authorMehmet Ilkin Naharci MD, Mehmet Ilkin Naharci MD Professor Gulhane Faculty of Medicine & Training and Research Hospital, Department of Internal Medicine, University of Health Sciences Turkiye, Ankara, TurkeySearch for more papers by this author First published: 24 October 2022 https://doi.org/10.1111/jocn.16567Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation 

Complexity of medication adherence among middle-aged and older adults (Comment on 'Association between cognitive function and self-reported antihypertensive medication adherence among middle-aged and older hypertensive women').

Background: Vaccination is one of the basic activities in preve ntive health care. Data related to vaccination in the elderly Turkish population is limited. The aim of the present study was to investigate the vaccina tion status and related factors among geriatric individuals. Methods: In this single center, cross sectional study self- reported status of vaccinations for influenza, pneumococcal, tetanus, pandemic influenza A/H1N1 and hepatitis B were recorded in people over 65 years of age. The information was collected separately for the last 12 months and for the last 5 years. Associ ates of having been vaccinated were also examined systematically.

/pdf/vaccination-status-and-related-factors-in-an-elderly-turkish-2c2kjs96cp.pdf

Vaccination status and related factors in an elderly Turkish population sample: A cross-sectional study

To the editor, Christiaens et al. have recently suggested in a Diabetic Medicine article that proposed definitions of diabetes overtreatment so far are not in agreement with each other.1 They also pointed out that a standardized definition could be based on individualized hypoglycaemia risk and/or complications. In 22 articles they evaluated, the prevalence of overtreatment, based on glycated haemoglobin and antidiabetic drug use, ranged from 9.2%2 to 79%,3 depending on the age group, comorbidity burden and setting.1 Overtreatment has been widely considered an issue of older age. When glycated haemoglobin is taken into account, it may be of marginal importance among subjects aged younger than 60 years.4 However, intensive treatmentrelated mortality increase in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial was not associated with symptomatic, severe hypoglycaemia, while the intensity of treatment was determined using glycated haemoglobin.5 An interesting finding in the ACCORD trial was the increased risk of cardiovascular disease and total mortality in younger participants, but not in older patients, following intensive glucose lowering (glycated haemoglobin <42 mmol/mol [<6.0%]).6 Hence, current data may be insufficient to address hypoglycaemia events or glycated haemoglobin <42 mmol/mol (<6.0%) as predictors of increased harm in older adults. Moreover, Lipska KJ et al. reported that severe hypoglycaemia was common among 9094 patients with type 2 diabetes (mean age: 59.5 years; range 30– 77 years) across all levels of glycaemic control, and the risk tended to be even higher in patients with either nearnormal glycaemia or very poor glycaemic control.7 On the other hand, the authors also showed that the prevalence of hypoglycaemia was similar across age groups (10.8% of <50 years of age, 10.6% of 50– 59 years of age, 11.3% of 60– 69 years of age, and 10.4% of 70– 79 years of age; p = 0.78), whereas diabetes duration >10 years, insulin therapy and using secretagogues did show associations with hypoglycaemia.7 Older adults are at increased risk of several agerelated conditions linked to increased morbidity and mortality when compared with middleaged or adult individuals. Concerning tight glucose control, an earlier study found evidence of an association with a glycated haemoglobin ≤ 53 mmol/mol (≤7.0%) with falls in the elderly, independent of frailty status.8 Nevertheless, a higher glycated haemoglobin may also be associated with serious outcomes among older adults with diabetes mellitus. Mitsios et al. reported that for every 1% glycated haemoglobin increment, the average hazard ratio for firstever stroke was significantly increased by 17% in individuals with diabetes mellitus.9 Moreover, a higher glycated haemoglobin was a predictor of ischemic stroke in people with or without diabetes mellitus.9 Finally, a recent study has shown an association of higher glycated haemoglobin with incident dementia, predominantly the vascular type, in these patients.10 In conclusion, deintensification of antidiabetic treatment, prioritizing the risky agents, may not always require loosening glycated haemoglobin targets in older adults. It should be emphasized that a higher glycated haemoglobin level may put older individuals, particularly the relatively healthy ones, at increased risk of other relevant conditions associated with mortality. In this context, performance measures like independence in activities of daily living, and cognitive and functional frailty may be the potential research targets to establish a robust definition of overtreatment.

The role of glycated haemoglobin in clinical decision‐making of diabetes overtreatment

For more than a decade, considerable attention has been focused on muscle mass, muscle function, or both, and their relationship with adverse health consequences in older people. Initially, muscle mass was given much importance [1]. However, there is accumulating evidence, that the “strength’’ of the muscle is more meaningful [2]. The most recent update from the European consensus group suggests the simultaneous use of muscle strength and muscle mass, with specific recommendations for clinical practice [3]. A recent article by Nishimura et al. published in Surgery Today concluded with findings of an association between sarcopenia and mortality in geriatric patients who suffered severe trauma [4]. Research on the association of adverse outcomes in such heterogeneous groups is very important and relevant to the care of an aging population worldwide. In elective surgery, sarcopenia was reported as a reliable indicator of postoperative complications and long-term mortality; however, limited data are available for geriatric trauma patients in the emergency setting [5]. Moreover, we would like to comment on some technical aspects of classifying an older adult with sarcopenia. The most recent European Working Group on Sarcopenia report recommends the assessment of handgrip strength in the first order [3]. When there is no reduction in adjusted grip strength, sarcopenia is considered unlikely [3]. This is in accordance with the understanding of the North American approach published several years ago [2]. Hence, muscle mass measurement, either through bioelectrical impedance analysis or psoas muscle area on computerized tomography (CT)/magnetic resonance imaging, is unlikely to be a single reliable indicator of deprived muscle dynamics according to current guidelines. Finally, the method used by Nishimura et al. to estimate the muscle mass using a single-slice CT of the L3 vertebra is not recommended in the recent Asian Working Group for Sarcopenia consensus update [6]. In addition to the above concerns that can cause misclassification of older adults with sarcopenia, other issues with the CT-guided muscle mass measurement need to be acknowledged. Tissue analysis via CT requires the calculation of tissue Hounsfield unit (HU) attenuations [7], which is not uniform in all scanners and can be challenging when working on contrast-enhanced images. [7, 8]. Thus, to control for such potential errors in research works, all measurements need to be done by the same CT scanner, and only non-contrast-enhanced images should be evaluated to maintain consistency in the classification of patients for sarcopenia. * Umut Safer umut.safer@sbu.edu.tr

Comment on "The psoas muscle index as a predictor of mortality and morbidity of geriatric trauma patients: experience of a major trauma center in Kobe."

Re. "Feasibility of substituting handgrip strength for muscle mass as a constituent standard in the Global Leadership Initiative on Malnutrition for diagnosing malnutrition in patients with gastrointestinal cancers".

Ilker Tasci

Papers

Complexity of medication adherence among middle-aged and older adults (Comment on 'Association between cognitive function and self-reported antihypertensive medication adherence among middle-aged and older hypertensive women').

Vaccination status and related factors in an elderly Turkish population sample: A cross-sectional study

The role of glycated haemoglobin in clinical decision‐making of diabetes overtreatment

Comment on "The psoas muscle index as a predictor of mortality and morbidity of geriatric trauma patients: experience of a major trauma center in Kobe."

Re. "Feasibility of substituting handgrip strength for muscle mass as a constituent standard in the Global Leadership Initiative on Malnutrition for diagnosing malnutrition in patients with gastrointestinal cancers".