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 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

Aim. The aim of this paper is to distinguish the integrative review method from other review methods and to propose methodological strategies specific to the integrative review method to enhance the rigour of the process.

Background.  Recent evidence-based practice initiatives have increased the need for and the production of all types of reviews of the literature (integrative reviews, systematic reviews, meta-analyses, and qualitative reviews). The integrative review method is the only approach that allows for the combination of diverse methodologies (for example, experimental and non-experimental research), and has the potential to play a greater role in evidence-based practice for nursing. With respect to the integrative review method, strategies to enhance data collection and extraction have been developed; however, methods of analysis, synthesis, and conclusion drawing remain poorly formulated.

Discussion.  A modified framework for research reviews is presented to address issues specific to the integrative review method. Issues related to specifying the review purpose, searching the literature, evaluating data from primary sources, analysing data, and presenting the results are discussed. Data analysis methods of qualitative research are proposed as strategies that enhance the rigour of combining diverse methodologies as well as empirical and theoretical sources in an integrative review.

Conclusion.  An updated integrative review method has the potential to allow for diverse primary research methods to become a greater part of evidence-based practice initiatives.

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The integrative review: updated methodology

Erik Eriksen is a remarkable individual. He has no college degrees yet is Professor of Human Development at Harvard University. He came to psychology via art, which explains why the reader will find him painting contexts and backgrounds rather than stating dull facts and concepts. He has been a training psychoanalyst for many years as well as a perceptive observer of cultural and social settings and their effect on growing up. This is not just a book on childhood. It is a panorama of our society. Anxiety in young children, apathy in American Indians, confusion in veterans of war, and arrogance in young Nazis are scrutinized under the psychoanalytic magnifying glass. The material is well written and devoid of technical jargon. The theme of the volume is that it is human to have a long childhood which will leave a lifelong residue of emotional immaturity in man. Primitive groups and

Childhood and Society.

D iabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education and support 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, payers, and other interested individuals with the components of diabetes care, general 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. Specifically titled sections of the standards address children with diabetes, pregnant women, and people with prediabetes. These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed. For more detailed information about management of diabetes, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A large number of these interventions have been shown to be cost-effective (4). A grading system (Table 1), developed by the American Diabetes Association (ADA) andmodeled after existingmethods, 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. These standards of care are revised annually by the ADA’s multidisciplinary Professional Practice Committee, incorporating new evidence. For the current revision, committee members systematically searched Medline for human studies related to each subsection and published since 1 January 2010. Recommendations (bulleted at the beginning of each subsection and also listed in the “Executive Summary: Standards of Medical Care in Diabetesd2012”) were revised based on new evidence or, in some cases, to clarify the prior recommendation or match the strength of the wording to the strength of the evidence. A table linking the changes in recommendations to new evidence can be reviewed at http:// professional.diabetes.org/CPR_Search. aspx. Subsequently, as is the case for all Position Statements, the standards of care were reviewed and approved by the ExecutiveCommittee of ADA’s Board ofDirectors, which includes health care professionals, scientists, and lay people. Feedback from the larger clinical community was valuable for the 2012 revision of the standards. Readers who wish to comment on the “Standards of Medical Care in Diabetesd2012” are invited to do so at http://professional.diabetes.org/ CPR_Search.aspx. Members of the Professional Practice Committee disclose all potential financial conflicts of interest with industry. These disclosures were discussed at the onset of the standards revisionmeeting. Members of the committee, their employer, and their disclosed conflicts of interest are listed in the “Professional PracticeCommitteeMembers” table (see pg. S109). The AmericanDiabetes Association funds development of the standards and all its position statements out of its general revenues and does not utilize industry support for these purposes.

https://www.science-open.com/document_file/bb04d9d0-b3df-4133-9494-e71e300f4279/PubMedCentral/bb04d9d0-b3df-4133-9494-e71e300f4279.pdf

Standards of Medical Care in Diabetes—2012

During recent years, the American Diabetes Association (ADA) has published detailed guidelines and recommendations for the management of diabetes in the form of technical reviews, position statements, and consensus statements. Recommendations regarding children and adolescents have generally been included as only a minor portion of these documents. For example, the most recent ADA position statement on “Standards of Medical Care for Patients With Diabetes Mellitus” (last revised October 2003) included “special considerations” for children and adolescents (1). Other position statements included age-specific recommendations for screening for nephropathy (2) and retinopathy (3) in children with diabetes. In addition, the ADA has published guidelines pertaining to certain aspects of diabetes that apply exclusively to children and adolescents, including care of children with diabetes at school (4) and camp (5) and a consensus statement on type 2 diabetes in children and adolescents (6).

The purpose of this document is to provide a single resource on current standards of care pertaining specifically to children and adolescents with type 1 diabetes. It is not meant to be an exhaustive compendium on all aspects of the management of pediatric diabetes. However, relevant references are provided and current works in progress are indicated as such. The information provided is based on evidence from published studies whenever possible and, when not, supported by expert opinion or consensus (7). Several excellent detailed guidelines and chapters on type 1 diabetes in pediatric endocrinology texts exist, including those by the International Society of Pediatric and Adolescent Diabetes (ISPAD) (8), by the Australian Pediatric Endocrine Group (www.chw.edu/au/prof/services/endocrinology/apeg), in Lifshitz’s Pediatric Endocrinology (9–11), and by Plotnick and colleagues (12,13).

Children have characteristics and needs that dictate different standards of care. The management of diabetes in children must take the major differences between children of various ages and …

/pdf/care-of-children-and-adolescents-with-type-1-diabetes-a-3dg1hpllcz.pdf

Care of Children and Adolescents With Type 1 Diabetes A statement of the American Diabetes Association

Chronic illnesses, such as cardiovascular disease, cancer, and diabetes, are among the most prevalent and costly of all global health problems (World Health Organization, 2011). They are the primary reason adults seek health care and are the leading cause of death and disability in the United States (U.S. Centers for Disease Control and Prevention, 2011). Chronic illnesses are long term, uncertain, and can be very intrusive to individuals' everyday lives (Larsen, 2009). Often, chronic illnesses have a course that varies over time specific to the etiology and physiology of the particular illness. However, there are common challenges across chronic illnesses, which include recognizing symptoms and taking appropriate actions, using medications effectively, managing complex regimens, developing strategies to deal with the psychological consequences of the illness, and interacting with the healthcare system over time (Wagner et al., 2001; U.K. Department of Health, 2003). Chronic illness management has been recognized as an important component of health care, and there is increasing awareness that similar strategies can be effective across different types of chronic illnesses (Dowrick, Dixon-Woods, Holman, & Weinman, 2005; Harvey et al., 2008; Swendeman, Ingram, Rotheram-Borus, 2009).

/pdf/processes-of-self-management-in-chronic-illness-2tapon5fus.pdf

Processes of Self-Management in Chronic Illness

Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life.

OBJECTIVE: Recommendations from the Diabetes Control and Complications Trial (DCCT) indicate that adolescents with type 1 diabetes should be treated with intensive therapy involving multiple daily injections (MDI) of insulin or insulin pump therapy (continuous subcutaneous insulin infusion [CSII] to help obtain better metabolic control and prevent later complications. Interest has thus focused on insulin pump therapy to help adolescents meet this challenge. The purpose of this study was to examine responses to CSII and MDI in a large group of adolescents with established type 1 diabetes during a 12-month period and to determine whether either treatment regimen more favorably affected clinical and psychosocial outcomes. RESEARCH DESIGN AND METHODS: One-third of 75 youths aged 12-20 years who were candidates for intensive therapy chose CSII as their mode of treatment. Patients received intensive treatment and education as described by the DCCT investigators. Psychosocial data (e.g., quality of life, depression, self-efficacy, and coping) were collected at baseline and at 6-month intervals, and clinical data (e.g., HbA1c levels, adverse events) were collected every 4-6 weeks. RESULTS: Although both MDI- and CSII-treated adolescents initially exhibited improved metabolic control, this level of control was more difficult to sustain for 12 months in the MDI group (at 6 months HbA1c = 8.1, at 12 months HbA1c = 8.3), whereas average HbA1c levels in the CSII group continued to decrease during the 12 months of treatment (at 6 months HbA1c = 7.7, at 12 months HbA1c = 7.5). Despite lower HbA1c levels in CSII-versus MDI-treated patients, the rate of severe hypoglycemic events was reduced by almost 50% in the CSII group (P = 0.01). Self-reported questionnaires demonstrated that there was improvement in self-efficacy, depression, and quality of life in both MDI- and CSII-treated patients. Finally, adolescents using CSII found coping with diabetes to be less difficult than adolescents using MDI did. CONCLUSIONS: CSII is an alternative means to lower HbA1c levels and reduce the risk of hypoglycemia without adversely affecting psychosocial outcomes in adolescents with type 1 diabetes.

Continuous subcutaneous insulin infusion. A new way to lower risk of severe hypoglycemia, improve metabolic control, and enhance coping in adolescents with type 1 diabetes.

In children with type 1 diabetes (T1DM), parents are ultimately responsible for daily management of T1DM, which has a significant impact on family life. Daily management of T1DM is time-consuming and requires a change to many well-established family routines. Although technological advances have greatly enhanced the ability of parents to monitor and manage T1DM in youth,1 the responsibility of T1DM management can contribute to parental stress, distress, and diminished quality of life. Understanding the experience of parenting a child with T1DM can provide insight into the challenges and needs of parents, thus informing the development of parental and/or family interventions. Considerable research has been undertaken to examine aspects of the parenting experience; however, there is a need to synthesize this literature to inform future research and clinical work.

Caring for a child with T1DM has been described as an overwhelming experience, requiring constant vigilance.2 Parents must come to terms with having a child with a life-threatening illness and carrying out a labor-intensive and complicated daily regimen.3 Parents live with constant worry about hypoglycemia or hyperglycemia, heightened feelings of responsibility for their child’s health, and the desire to promote optimal growth and development.4 At different developmental phases, new issues arise that require a complete reevaluation of previously established and effective management strategies.5 The ongoing stress and worry manifest in elevated rates of parents’ perception of stress and increased risk for depression and anxiety.

There is considerable research on the prevalence of parental psychological distress and the impact of such distress on child and family outcomes. Although the majority of parents of children with T1DM adjust well, approximately 20% to 30% of parents report clinically significant distress, which has been defined as stress (life stress or parenting stress) and symptoms of anxiety, depression, and/or posttraumatic stress.6–8 Parental psychological distress at the time of diagnosis has been found to predict later parental distress.9 In addition, parental psychological distress has health implications for the parent, the child with T1DM, and the overall functioning of the family.10 In parents of children with T1DM, psychological distress has been shown to affect family communication,11 increase family conflict,12 decrease the ability to parent effectively,13 negatively affect child psychological adjustment,9 and contribute to poor parental mental and physical health.14

Greater understanding of the relationship of parental psychological responses to having a child with T1DM is needed to guide clinical practice and future research. Thus, the purpose of this systematic mixed-studies review is to synthesize the research on the parental experience of having a child with T1DM, focusing on parental psychological adjustment. The aims are to describe the prevalence of psychological distress in parents of children with T1DM, the relationship between parental psychological distress and health outcomes, and the parental experience of having a child with T1DM. Clinical and research implications will also be presented.

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Margaret Grey

Papers

Care of Children and Adolescents With Type 1 Diabetes A statement of the American Diabetes Association

Processes of Self-Management in Chronic Illness

Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life.

Continuous subcutaneous insulin infusion. A new way to lower risk of severe hypoglycemia, improve metabolic control, and enhance coping in adolescents with type 1 diabetes.

Psychological Experience of Parents of Children With Type 1 Diabetes A Systematic Mixed-Studies Review