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

The purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults." The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.

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Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise

Summary—In 1995 the American College of Sports Medicine and the Centers for Disease Control and Prevention published national guidelines on Physical Activity and Public Health The Committee on Exercise and Cardiac Rehabilitation of the American Heart Association endorsed and supported these recommendations The purpose of the present report is to update and clarify the 1995 recommendations on the types and amounts of physical activity needed by healthy adults to improve and maintain health Development of this document was by an expert panel of scientists, including physicians, epidemiologists, exercise scientists, and public health specialists This panel reviewed advances in pertinent physiologic, epidemiologic, and clinical scientific data, including primary research articles and reviews published since the original recommendation was issued in 1995 Issues considered by the panel included new scientific evidence relating physical activity to health, physical activity recommendations by various organizations in the interim, and communications issues Key points related to updating the physical activity recommendation were outlined and writing groups were formed A draft manuscript was prepared and circulated for review to the expert panel as well as to outside experts Comments were integrated into the final recommendation Primary Recommendation—To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week [I (A)] Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation [IIa (B)] For example, a person can meet the recommendation by walking briskly for 30 min twice during the week and then jogging for 20 min on two other days Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-min minimum by performing bouts each lasting 10 or more minutes [I (B)] Vigorous-intensity activity is exemplified by jogging, and causes rapid breathing and a substantial increase in heart rate In addition, every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week [IIa (A)] Because of the dose-response relation between physical activity and health, persons who wish to further improve their personal fitness, reduce their risk for chronic diseases and disabilities or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity [I (A)] (Circulation 2007;116:1081-1093)

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Physical Activity and Public Health Updated Recommendation for Adults From the American College of Sports Medicine and the American Heart Association

The metabolic syndrome

Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

A lifelong pursuit such as medicine is frequently paired with a framework of “deliberate practice” for improvement. It is unclear whether the quality of feedback varies across different learner levels. Our study aims to assess whether a difference exists in the quality of feedback delivered to high‐, expected‐, and below‐expected performer emergency medicine (EM) residents based on their attending‐identified performance level.

Differences in faculty feedback for high, expected, and below‐expected clinically performing emergency medicine residents

FUNDAMENTOS: El cateterismo uretral es el metodo de eleccion para obtener muestras de orina para cultivo y analisis en ninos pequenos. Antes de efectuar el procedimiento no suele tenerse la certeza de que haya orina en la vejiga. En consecuencia, este procedimiento relativamente invasivo y molesto a veces se ha de repetir. La nueva tecnologia disponible, el ecografo portatil, puede ser util para reducir el numero de cateterizaciones infructuosas. OBJETIVO: Investigar la utilidad de la ecografia de la vejiga a la cabecera del enfermo realizada por los medicos de urgencias pediatricas antes de los sondajes uretrales para reducir el numero de procedimientos que fracasan. METODOS: Se ha llevado a cabo un estudio prospectivo en 2 fases en un servicio de urgencias pediatricas urbano entre agosto de 2003 y febrero de 2004. Se incluyo a los ninos entre 0 y 24 meses de edad. Durante la fase de observacion se registro la cantidad de orina obtenida en el primer intento con cada paciente. Durante el periodo de intervencion, un medico de urgencias pediatricas efectuo una ecografia vesical rapida a la cabecera del paciente inmediatamente antes del cateterismo uretral. Si se observaba una cantidad de orina suficiente, se llevaba a cabo el cateterismo como habitualmente. Si no era asi, el cateterismo se posponia y se repetia la ecografia a intervalos de 30 min hasta que se observara suficiente cantidad de orina. Se anoto la cantidad de orina. RESULTADOS: Durante la fase de observacion, 136 lactantes fueron sometidos a cateterismo uretral. Globalmente, la tasa de exito, definida como la obtencion de mas de 2 ml de orina, suficiente para el urocultivo y para otros estudios de rutina, ha sido del 72% (intervalo de confianza del 95%, 66-78%). Durante la fase de intervencion, se incluyo a 112 sujetos. Se identifico la presencia de orina suficiente en la primera ecografia en el 76% (n = 85) de los pacientes. Entre ellos, el 98% (n = 83) se sometieron con exito a un cateterismo uretral al primer intento. Entre los que inicialmente no tenian suficiente orina (n = 27; 24%), una ecografia posterior mostro una cantidad suficiente en todos los pacientes en los 90 min siguientes. Entre ellos, el 93% (n = 25) fueron sometidos con exito a un cateterismo uretral al primer intento. La tasa global de exito del cateterismo uretral inicial durante la fase de intervencion fue del 96% (intervalo de confianza del 95%, 93-99%). En comparacion con la tasa de exito durante la fase de observacion, la diferencia resulto estadisticamente significativa (p < 0,001). Los resultados se mantuvieron despues de ajustar por el sexo. CONCLUSION: Una ecografia vesical rapida realizada a la cabecera del paciente por medicos de urgencias pediatricas permite una mayor tasa de exito del cateterismo uretral en ninos menores de 2 anos. Podemos evitar pruebas invasivas repetidas, con un sencillo procedimiento no invasivo.

James Dziura

Papers

Differences in faculty feedback for high, expected, and below‐expected clinically performing emergency medicine residents

Utilidad de la ecografía vesical a la cabecera del enfermo antes del cateterismo uretral en niños pequeños