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

Co-Planar Stereotaxic Atlas of the Human Brain—3-Dimensional Proportional System: An Approach to Cerebral Imaging, J. Talairach, P. Tournoux. Georg Thieme Verlag, New York (1988), 122 pp., 130 figs. DM 268

Prospective Cohort Study

1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

Although COVID-19 is most well known for causing substantial respiratory pathology, it can also result in several extrapulmonary manifestations. These conditions include thrombotic complications, myocardial dysfunction and arrhythmia, acute coronary syndromes, acute kidney injury, gastrointestinal symptoms, hepatocellular injury, hyperglycemia and ketosis, neurologic illnesses, ocular symptoms, and dermatologic complications. Given that ACE2, the entry receptor for the causative coronavirus SARS-CoV-2, is expressed in multiple extrapulmonary tissues, direct viral tissue damage is a plausible mechanism of injury. In addition, endothelial damage and thromboinflammation, dysregulation of immune responses, and maladaptation of ACE2-related pathways might all contribute to these extrapulmonary manifestations of COVID-19. Here we review the extrapulmonary organ-specific pathophysiology, presentations and management considerations for patients with COVID-19 to aid clinicians and scientists in recognizing and monitoring the spectrum of manifestations, and in developing research priorities and therapeutic strategies for all organ systems involved.

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Extrapulmonary manifestations of COVID-19.

This case report describes birth of an infant with elevated anti–SARS-CoV-2 IgM antibodies and cytokine levels to a mother with polymerase chain reaction–confirmed coronavirus disease 2019 (COVID-19) despite no physical contact.

https://jamanetwork.com/journals/jama/articlepdf/2763853/jama_dong_2020_ld_200024.pdf

Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn.

To explore the changes of brain structure and function in attention-deficit/hyperactivity disorder (ADHD), fifteen ADHD patients (inattention subtype) and 15 normal control participants were recruited, the brain structure and function of these subjects were investigated by combining structural magnetic resonance imaging (MRI), diffusion tensor imaging and resting-state functional MRI. The results showed that ADHD patients had a significant decrease in the volume of the white matter (P = 0.04), and a trend toward decreased volume of brain structures except for the putamen and globus pallidus. The visualization of statistical difference maps of the cortical thickness showed that ADHD patients had focal thinning in bilateral frontal regions and the right cingulate cortex (P < 0.05 uncorrected, except for a cluster threshold of 10 voxels). Statistical analysis of the FA maps revealed that ADHD patients had significantly decreased FA in the forceps minor, the internal capsule, the corona radiata, the splenium of the corpus callosum, and the bilateral basal ganglia (P < 0.05 uncorrected as above). ADHD patients had significantly decreased functional connectivity in the anterior cingulate cortex, posterior cingulate cortex, lateral prefrontal cortex, left precuneus and thalamus, but increased functional connectivity in bilateral posterior medial frontal cortex in the default mode network (P < 0.05 uncorrected as above). Our results provide new insights into the changes of the brain structure and function in ADHD, which suggests that alterations in the brain structural and functional connectivity might implicate the pathophysiology of ADHD.

Changes of brain structure and function in ADHD children.

Objective To perform a meta-analysis exploring the correlation between the apparent diffusion coefficient (ADC) and tumor cellularity in patients. Materials and Methods We searched medical and scientific literature databases for studies discussing the correlation between the ADC and tumor cellularity in patients. Only studies that were published in English or Chinese prior to November 2012 were considered for inclusion. Summary correlation coefficient (r) values were extracted from each study, and 95% confidence intervals (CIs) were calculated. Sensitivity and subgroup analyses were performed to investigate potential heterogeneity. Results Of 189 studies, 28 were included in the meta-analysis, comprising 729 patients. The pooled r for all studies was −0.57 (95% CI: −0.62, −0.52), indicating notable heterogeneity (P<0.001). After the sensitivity analysis, two studies were excluded, and the pooled r was −0.61 (95% CI: −0.66, −0.56) and was not significantly heterogeneous (P = 0.127). Regarding tumor type subgroup analysis, there were sufficient data to support a strong negative correlation between the ADC and cellularity for brain tumors. There was no notable evidence of publication bias. Conclusions There is a strong negative correlation between the ADC and tumor cellularity in patients, particularly in the brain. However, larger, prospective studies are warranted to validate these findings in other cancer types.

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The correlation between apparent diffusion coefficient and tumor cellularity in patients: a meta-analysis.

The authors followed 5,437 people aged 55 years and older with normal baseline Mini-Mental State Examination score annually for 5 years. The mean incidence of cognitive impairment was 2.3% per year. Cognitive activities in both the individual item (playing board games and reading) and the composite measure were associated with the reduced risk of cognitive impairment, while watching television was associated with an increased risk of cognitive impairment.

Leisure activity and risk of cognitive impairment: The Chongqing aging study

Since the first case of a coronavirus disease 2019 (COVID-19) infection pneumonia was detected in Wuhan, China, a series of confirmed cases of the COVID-19 were found in Southwest China. The aim of this study was to describe the imaging manifestations of hospitalized patients with confirmed COVID-19 infection in southwest China. In this retrospective study, data were collected from 131 patients with confirmed coronavirus disease 2019 (COVID-19) from 3 Chinese hospitals. Their common clinical manifestations, as well as characteristics and evolvement features of chest CT images, were analyzed. A total of 100 (76%) patients had a history of close contact with people living in Wuhan, Hubei. The clinical manifestations of COVID-19 included cough, fever. Most of the lesions identified in chest CT images were multiple lesions of bilateral lungs, lesions were more localized in the peripheral lung, 109 (83%) patients had more than two lobes involved, 20 (15%) patients presented with patchy ground glass opacities, patchy ground glass opacities and consolidation of lesions co-existing in 61 (47%) cases. Complications such as pleural thickening, hydrothorax, pericardial effusion, and enlarged mediastinal lymph nodes were detected but only in rare cases. For the follow-up chest CT examinations (91 cases), We found 66 (73%) cases changed very quickly, with an average of 3.5 days, 25 cases (27%) presented absorbed lesions, progression was observed in 41 cases (46%), 25 (27%) cases showed no significant changes. Chest CT plays an important role in diagnosing COVID-19. The imaging pattern of multifocal peripheral ground glass or mixed consolidation is highly suspicious of COVID-19, that can quickly change over a short period of time.

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Jian Wang

Papers

Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn.

Changes of brain structure and function in ADHD children.

The correlation between apparent diffusion coefficient and tumor cellularity in patients: a meta-analysis.

Leisure activity and risk of cognitive impairment: The Chongqing aging study

CT imaging changes of corona virus disease 2019(COVID-19): a multi-center study in Southwest China.