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

I first read Davidson 30 years ago: at that time it was already in its 5th edition. A brief comparison shows that it then contained about 440,000 words in 1,100 pages: the current edition has compressed 625,000 words into 800 pages. I think I bought it as a student because it was cheap: but also because it seemed to be comprehensive and straightforward, and I have used it as a basis for my medical knowledge ever since. So I miss some of the old pictures of the acute skin rashes such as scarlet fever: in fact infectious disease has been transferred to the back and genetic factors take the first chapters. But careful linguistic comparison will still uncover the old phrases which some of us know by heart-there are minor changes such as 'alarming reactions to intravenous iron are uncommon, but have occasionally been noted', which becomes 'alarming systemic anaphyllactic reactions can occur'. Sir Stanley Davidson made 'no attempt to describe every rare disease or syndrome, but devoted most of the space available to those disorders most commonly encountered in practice'. I have grown up with successive editions, and have gradually come to appreciate the problems of the authors in the compression of knowledge. Having got to know many of them personally as real people rather than as names I can still recommend the book. It is the essential starting point for the study of internal medicine and for many doctors will remain their base reference work. The present editors have kept up-to-date and been prepared to prune the dead wood. There are many competitors in the market, and the publishers must take care with layout and illustration, although Davidson is still the best value for money. I will continue to recommend it to my clinical students: they will need to read it and know it to pass final MB. Postgraduates will need to remember the facts, but also to be able to place them in a broader perspective. The older consultant will still happily read it, and to get to know the authors themselves is really to complete your medical education. Dr John Macleod and his team have successfully kept alive the primary objective 'to provide a rational and easily comprehensible basis for the practice of medicine'. The book is economical in price and compact in size, but still contains the essential truths for the practice of good medicine.

Davidson's Principles and Practice of Medicine

CONTEXT\nKnowledge about ethnic differences in cardiovascular disease (CVD) risk factors among children and young adults from national samples is limited.\n\n\nOBJECTIVE\nTo evaluate ethnic differences in CVD risk factors, the age at which differences were first apparent, and whether differences remained after accounting for socioeconomic status (SES).\n\n\nDESIGN\nThird National Health and Nutrition Examination Survey, 1988-1994.\n\n\nSETTING\nEighty-nine mobile examination centers.\n\n\nPARTICIPANTS\nA total of 2769 black, 2854 Mexican American, and 2063 white (non-Hispanic) children and young adults aged 6 to 24 years.\n\n\nMAIN OUTCOME MEASURES\nEthnicity and household level of education (SES) in relation to body mass index (BMI), percentage of energy from dietary fat, cigarette smoking, systolic blood pressure, glycosylated hemoglobin (HbA1c), and non-high-density lipoprotein cholesterol (non-HDL-C [the difference between total cholesterol and HDL-C]).\n\n\nRESULTS\nThe BMI levels were significantly higher for black and Mexican American girls than for white girls, with ethnic differences evident by the age of 6 to 9 years (a difference of approximately 0.5 BMI units) and widening thereafter (a difference of >2 BMI units among 18- to 24-year-olds). Percentages of energy from dietary fat paralleled these findings and were also significantly higher for black than for white boys. Blood pressure levels were higher for black girls than for white girls in every age group, and glycosylated hemoglobin levels were highest for black and Mexican American girls and boys in every age group. In contrast, smoking prevalence was highest for white girls and boys, especially for those from low-SES homes (77% of young men and 61% of young women, aged 18-24 years, from low-SES homes were current smokers). All ethnic differences remained significant after accounting for SES and age.\n\n\nCONCLUSION\nThese findings show strong ethnic differences in CVD risk factors among youths of comparable age and SES from a large national sample. The differences highlight the need for heart disease prevention programs to begin early in childhood and continue throughout young adulthood to reduce the risk of atherosclerosis.

Ethnic variation in cardiovascular disease risk factors among children and young adults : Findings from the Third National Health and Nutrition Examination Survey, 1988-1994.

It is well accepted that there is a clear and direct relationship between the incidence of ischemic heart disease and elevations in both total plasma cholesterol and low-density lipoprotein (LDL-C). However, as physicians and in particular as insurance physicians, we have all seen cases in which there is a history of ischemic heart disease with normal or even low cholesterol readings. Some studies suggest that this could even be as high as 50% of all ischemic heart disease cases. So it stands to reason that cholesterol, while clearly the culprit in many patients, is not the complete answer to the etiology of ischemic heart disease.

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Fasting insulin and apolipoprotein B levels and low density lipoprotein particle size as risk factors for ischemic heart disease.

RATIONALE
In a large proportion of patients with active pulmonary tuberculosis (pTB), acid-fast bacilli smear results for sputum and bronchial secretions are negative. Detectable growth of Mycobacterium tuberculosis (MTB) in cultures takes several weeks and MTB-specific DNA amplification results on sputum and bronchial secretions are variable in these patients.


OBJECTIVE
We investigated whether a rapid diagnosis of pTB can be established by enumeration of MTB-specific mononuclear cells from bronchoalveolar lavage (BAL) fluid in routine clinical practice.


METHODS
Patients presenting to a tertiary hospital with medical histories and pulmonary infiltrates compatible with tuberculosis, and negative acid-fast bacilli smear results (three) from sputum, were prospectively enrolled in this study. An MTB-specific enzyme-linked immunospot assay (ELISPOT [T-SPOT.TB; Oxford Immunotec, Abingdon, UK]) with early antigenic target-6 (ESAT-6) and culture filtrate protein-10 (CFP-10) peptides was performed on peripheral blood mononuclear cells (PBMCs) and mononuclear cells from the BAL fluid (BALMCs).


MEASUREMENTS AND MAIN RESULTS
Of 37 patients, 12 were found to have smear-negative pTB and 25 were found to have an alternative diagnosis. Patients with tuberculosis had a median number of 17 ESAT-6-specific cells and 24.5 CFP-10-specific cells per 200,000 PBMCs and 37.5 ESAT-6-specific cells and 49.5 CFP-10-specific cells per 200,000 cells in the BAL fluid. Control patients had a median of 1 ESAT-6-specific cell and 1 CFP-10-specific cell per 200,000 PBMCs and no ESAT-6- and CFP-10-specific cells per 200,000 cells in the BAL fluid (p < 0.0001). All patients with TB but none of the control subjects had more than 5 spot-forming cells per 200,000 BALMCs with either peptide in the BAL fluid ELISPOT.


CONCLUSION
Smear-negative pulmonary tuberculosis can be diagnosed rapidly by identification of MTB-specific cells in the BAL fluid.

Rapid diagnosis of smear negative tuberculosis by bronchoalveolar-lavage enzyme-linked immunospot: an update

Present study was undertaken during a period of 6 months (September 2008-February 2009) to see an correlation of 24 hours urine protein estimation with random spot protein-creatinine (P:C) ratio among a diabetic patients. The study comprised of 144 patients aged 30-70 years, recruited from Kantipur hospital, Kathmandu. The 24-hr urine sample was collected, followed by spot random urine sample. Both samples were analyzed for protein and creatinine excretion. An informed consent was taken from all participants. Sixteen inadequately collected urine samples as defined by (predicted creatinine--measured creatinine)/predicted creatinine > 0.2 were excluded from analysis. The Spearman's rank correlation between the spot urine P:C ratio and 24-hr total protein were performed by the Statistical Package for Social Service. At the P:C ratio cutoff of 0.15 and reference method (24-hr urine protein) cutoff of 150 mg/day, the correlation coefficient was found to be 0.892 (p < 0.001). The area under ROC curve at different cutoffs was 0.88 at 95.0% CI. The sensitivity and specificity of the P:C ratio to detect significant proteinuria at the cutoff of 0.15 are 96.6% and 74.4%. So the P:C ratio can predict significant proteinuria in diabetic subjects, avoiding the inconvenient 24-hr urine collection but the cutoff should be carefully selected for different patients group under different laboratory procedures and settings.

/pdf/use-of-protein-creatinine-ratio-in-a-random-spot-urine-4fuydcii72.pdf

Use of protein: creatinine ratio in a random spot urine sample for predicting significant proteinuria in diabetes mellitus.

Background: Diabetes mellitus (DM) is characterized by a broad disturbance in metabolism. Since the liver plays a vital role in the regulation of metabolism, there is evidence of liver dysfunction in DM. There is a high prevalence of non-alcoholic fatty liver disease among diabetic patients in western countries. However, there is a paucity of data showing of such association in Nepalese patients with DM. Therefore, the present study was carried out for a better understanding of alteration of liver function in patients with type 2 DM (T2DM). Methods: A total of 105 patients (age between 30-74 years, male/female ratio=0.6), newly Original Research Article Shrestha et al.; IJBCRR, 16(1): 1-8, 2017; Article no.IJBCRR.31935 2 diagnosed as T2DM, without the history of liver disease and other chronic diseases, were recruited from out-patient department of Nepal Medical College Teaching Hospital along with 58 age and sex matched healthy controls (age between 30-71 years, male/female ratio=0.7). After basic anthropometric measurements, fasting venous blood was collected and subjected to analysis for liver enzymes. Results: We observed marginal, yet statistically significant increase of serum alanine transferase (26.6±0.84 (diabetic) vs 20.0±0.69 (control), p=0.003) and γ-glutamyl transferase (40.4±1.51(diabetic) vs 21.2±1.1(control), p<0.001) in the diabetic patients compared to healthy controls. Conclusion: The liver enzymes were marginally elevated in T2DM compared to controls. This increment may be associated with early pathological changes in the liver. Hence, regular monitoring of liver function is highly beneficial to prevent advance liver injury in T2DM.

/pdf/hepatic-involvement-with-elevated-liver-enzymes-in-nepalese-495icyerab.pdf

Hepatic Involvement with Elevated Liver Enzymes in Nepalese Subjects with Type 2 Diabetes Mellitus

Product of serum calcium and phosphorus (Ca × PO4) as predictor of cardiovascular disease risk in predialysis patients

Atherogenic index of plasma for prediction of future cardiovascular disease in prediabetes and diabetes population

Dyslipidemia is one of the primary causes for cardio vascular disease (CVD) and development of myocardial infarction (MI) which often leads to coronary artery disease (CAD). The elevated level of total cholesterol (TC), triglycerides (TG), low-density lipoproteins-cholesterol (LDL-C), and lowered high-density lipoprotein-cholesterol (HDL-C) are the predictable risk factor for CAD with type-II diabetic patient. The present study was undertaken taken with an objective to frame out the lipid profile in type-II diabetic patients attending OPD (outpatient department) of Nepal Medical College Teaching Hospital (NMCTH) Jorpati, Kathmandu. Samples of 148 individuals with age varying from 30-73 were analyzed. Out of which 96 patients were diabetic and 52 were control group. The mean +/- SD (mg/dl) levels of Cholesterol, TG and LDL-C were found significantly higher compared to non-diabetic, and these are statistically significant when compared with healthy control group. The study concludes that the study of accessing fasting lipid profile in type-II diabetic will be a tool of accessing risk for cardiovascular and other coronary artery complications.

/pdf/study-of-fasting-serum-lipid-and-lipoproteins-profile-in-3hgmnmd8lc.pdf

Madhav Khanal

Papers

Use of protein: creatinine ratio in a random spot urine sample for predicting significant proteinuria in diabetes mellitus.

Hepatic Involvement with Elevated Liver Enzymes in Nepalese Subjects with Type 2 Diabetes Mellitus

Product of serum calcium and phosphorus (Ca × PO4) as predictor of cardiovascular disease risk in predialysis patients

Atherogenic index of plasma for prediction of future cardiovascular disease in prediabetes and diabetes population

Study of fasting serum lipid and lipoproteins profile in type-II diabetic patients attending NMCTH.