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 Pharmacological Basis of Therapeutics A Textbook of Pharmacology, Toxicology and Therapeutics for Physicians and Medical Students. By Prof. Louis Goodman and Prof. Alfred Gilman. Pp. xiii + 1383. (New York: The Macmillan Company, 1941.) 50s. net.

The Pharmacological Basis of Therapeutics

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

OBJECTIVE —In recent years, several major organizations have endorsed the concept of the metabolic syndrome and developed working definitions for it. How well these definitions predict the risk for adverse events in people with the metabolic syndrome is only now being learned. The purpose of this study was to summarize the estimates of relative risk for all-cause mortality, cardiovascular disease, and diabetes reported from prospective studies in samples from the general population using definitions of the metabolic syndrome developed by the National Cholesterol Education Program (NCEP) and World Health Organization (WHO). RESEARCH DESIGN AND METHODS —The author reviewed prospective studies from July 1998 through August 2004. RESULTS —For studies that used the exact NCEP definition of the metabolic syndrome, random-effects estimates of combined relative risk were 1.27 (95% CI 0.90–1.78) for all-cause mortality, 1.65 (1.38–1.99) for cardiovascular disease, and 2.99 (1.96–4.57) for diabetes. For studies that used the most exact WHO definition of the metabolic syndrome, the fixed-effects estimates of relative risk were 1.37 (1.09–1.74) for all-cause mortality and 1.93 (1.39–2.67) for cardiovascular disease; the fixed-effects estimate was 2.60 (1.55–4.38) for coronary heart disease. CONCLUSIONS —These estimates suggest that the population-attributable fraction for the metabolic syndrome, as it is currently conceived, is ∼6–7% for all-cause mortality, 12–17% for cardiovascular disease, and 30–52% for diabetes. Further research is needed to establish the use of the metabolic syndrome in predicting risk for death, cardiovascular disease, and diabetes in various population subgroups.

https://care.diabetesjournals.org/content/diacare/28/7/1769.full.pdf

Risks for all-cause mortality, cardiovascular disease, and diabetes associated with the metabolic syndrome: a summary of the evidence.

Summary Type 1 diabetes is a chronic autoimmune disease characterised by insulin deficiency and resultant hyperglycaemia. Knowledge of type 1 diabetes has rapidly increased over the past 25 years, resulting in a broad understanding about many aspects of the disease, including its genetics, epidemiology, immune and β-cell phenotypes, and disease burden. Interventions to preserve β cells have been tested, and several methods to improve clinical disease management have been assessed. However, wide gaps still exist in our understanding of type 1 diabetes and our ability to standardise clinical care and decrease disease-associated complications and burden. This Seminar gives an overview of the current understanding of the disease and potential future directions for research and care.

Type 1 diabetes

Registro de hipertrigliceridemias de la Sociedad Española de Arteriosclerosis

Avances en el tratamiento de la hipercolesterolemia

. Ademas, existe cierta tendencia a infrautilizar los recursos terapeuticos y preventivos en los ancianos. Las enfermedades tiroideas son muy prevalentes en el anciano, pero su diagnostico y tratamiento difiere de los estandares establecidos en la poblacion de mediana edad 5 , debido a las modificaciones que se producen con el envejecimiento, que conducen a cambios morfologicos y funcionales del tiroides que dificultan la interpretacion de las pruebas diagnosticas. A estos cambios se unen las alteraciones que sobre la funcion tiroidea tienen otras enfermedades intercurrentes, no tiroideas, muy frecuentes entre los ancianos, y las interacciones farmacologicas. Ademas, en el anciano debemos tener en cuenta que las manifestaciones clinicas de la enfermedad tiroidea son diferentes, generalmente atipicas, lo que dificulta su diagnostico. Por otra parte, tanto el hipertiroidismo como el hipotiroidismo no tratados aumentan la morbilidad por el agravamiento de enfermedades cardiovasculares coexistentes, muy prevalentes en la poblacion anciana6. Finalmente, el tratamiento de la enfermedad tiroidea puede aumentar el riesgo de complicaciones en el anciano. Todo esto destaca el interes que las enfermedades tiroideas tienen en el anciano.

Hipertiroidismo en el anciano

Resumen Introduccion y objetivos La menor prevalencia de diabetes mellitus tipo 2 (DM2) en pacientes con hipercolesterolemia familiar heterocigota (HFHe) podria explicar por que la DM2 no siempre se ha descrito como un predictor de enfermedad cardiovascular (ECV) en estos pacientes. El objetivo del presente estudio fue evaluar los aspectos clinicos y geneticos de pacientes con HFHe y DM2 del registro de dislipidemias de la Sociedad Espanola de Arteriosclerosis. Metodos Los pacientes con HFHe se clasificaron segun la presencia/ausencia de DM2. Se compararon las caracteristicas clinicas, bioquimicas y geneticas de ambos grupos. Resultados De los 2.301 casos de hipercolesterolemia primaria del registro, se incluyeron 1.724 casos con el diagnostico cierto o probable segun la Dutch Lipid Clinic Network para la hipercolesterolemia familiar. Los pacientes con HFHe y DM2 presentaron una tasa mas elevada de ECV y un perfil lipidico menos favorable, con niveles mas elevados de colesterol total (366,9 ± 86,7 mg/dl frente a 342,0 ± 74,7 mg/dl; diferencia media 24,894; IC95%, 5,840-43,949) y colesterol no-unido a lipoproteinas de alta densidad (316,9 ± 87,8 mg/dl frente a 286,4 ± 75,4 mg/dl; diferencia media 30,500; IC95%, 11,211-49,790). No se encontraron diferencias significativas entre los grupos con respecto al tipo de mutacion (p = 0,720). Despues de ajustar por los principales factores de riesgo, el analisis de regresion logistica confirmo una relacion entre la DM2 y la ECV (OR = 2,01; IC95%, 1,18-3,43; p = 0,010). Conclusiones Los pacientes con HFHe y DM2 presentan una tasa mas elevada de ECV y un perfil lipidico menos favorable, independientemente del tipo de mutacion. La diabetes mellitus es un factor asociado a la presencia de ECV en estos pacientes.

Juan F. Ascaso

Papers

Registro de hipertrigliceridemias de la Sociedad Española de Arteriosclerosis

Avances en el tratamiento de la hipercolesterolemia

Hipertiroidismo en el anciano

Diferencias clínicas y genéticas de los pacientes con hipercolesterolemia familiar heterocigota con y sin diabetes mellitus tipo 2

Validez de la valoración subjetiva global como método de despistaje de desnutrición hospitalaria. Prevalencia de desnutrición en un hospital terciario