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

Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults. PIMs now form an integral part of policy and practice and are incorporated into several quality measures. The specific aim of this project was to update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events (ADEs) in older adults. This was accomplished through the support of The American Geriatrics Society (AGS) and the work of an interdisciplinary panel of 11 experts in geriatric care and pharmacotherapy who applied a modified Delphi method to the systematic review and grading to reach consensus on the updated 2012 AGS Beers Criteria. Fifty-three medications or medication classes encompass the final updated Criteria, which are divided into three categories: potentially inappropriate medications and classes to avoid in older adults, potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and finally medications to be used with caution in older adults. This update has much strength, including the use of an evidence-based approach using the Institute of Medicine standards and the development of a partnership to regularly update the Criteria. Thoughtful application of the Criteria will allow for (a) closer monitoring of drug use, (b) application of real-time e-prescribing and interventions to decrease ADEs in older adults, and (c) better patient outcomes.

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American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults

This sales letter may not influence you to be smarter, but the book that we offer will evoke you to be smarter. Yeah, at least you'll know more than others who don't. This is what called as the quality life improvisation. Why should this research methods in social relations? It's because this is your favourite theme to read. If you like this theme about, why don't you read the book to enrich your discussion?

Research methods in social relations

The self-medication hypothesis of addictive disorders derives primarily from clinical observations of patients with substance use disorders. Individuals discover that the specific actions or effects of each class of drugs relieve or change a range of painful affect states. Self-medication factors occur in a context of self-regulation vulnerabilities--primarily difficulties in regulating affects, self-esteem, relationships, and self-care. Persons with substance use disorders suffer in the extreme with their feelings, either being overwhelmed with painful affects or seeming not to feel their emotions at all. Substances of abuse help such individuals to relieve painful affects or to experience or control emotions when they are absent or confusing. Diagnostic studies provide evidence that variously supports and fails to support a self-medication hypothesis of addictive disorders. The cause-consequence controversy involving psychopathology and substance use/abuse is reviewed and critiqued. In contrast, clinical observations and empirical studies that focus on painful affects and subjective states of distress more consistently suggest that such states of suffering are important psychological determinants in using, becoming dependent upon, and relapsing to addictive substances. Subjective states of distress and suffering involved in motives to self-medicate with substances of abuse are considered with respect to nicotine dependence and to schizophrenia and posttraumatic stress disorder comorbid with a substance use disorder.

The self-medication hypothesis of substance use disorders: a reconsideration and recent applications.

This investigation characterized the symptom patterns and mental status changes precipitated by anabolic steroid abuse. Twenty male weightlifters who were currently using anabolic steroids were compared to 20 male weightlifters who had never used steroids. The steroid users had significantly (p < 0.005) more somatic, depressive, anxiety, hostility, and paranoid complaints when using steroids than when they were not using the drugs. When contrasted to the weightlifter controls, the steroid users had a significantly (p < 0.005) greater number of complaints of depression, anxiety, and hostility during cycles of steroid use. However, no differences in the frequency of major mental disorders were found between the two groups. It is concluded that the organic affective changes associated with anabolic steroid abuse usually present as a subsyndromal depressive disorder of insufficient severity to be classified as a psychiatric disorder.

Psychiatric Symptoms Associated with Anabolic Steroids: A Controlled, Retrospective Study

Andropause, a syndrome in aging men, consists of physical, sexual, and psychologic symptoms that include weakness, fatigue, reduced muscle and bone mass, impaired hematopoiesis, oligospermia, sexual dysfunction, depression, anxiety, irritability, insomnia, memory impairment, and reduced cognitive function Free testosterone levels begin to decline at a rate of 1% per year after age 40 years It is estimated that 20% of men aged 60-80 years have levels below the lower limit of normal Although the causal relationship between declining testosterone levels and development of andropause symptoms is not firmly established, administration of testosterone to this population resulted in improvements in many areas Most studies to date focused on physical benefits of testosterone replacement and failed to assess psychologic symptoms rigorously Preliminary data suggest that therapy may benefit elderly men with new-onset depression Testosterone administration is not without problems, the most worrisome being the potential for increased prostate cancer risk Despite this concern, a limited number of studies administered the hormone weekly for up to 2 years, with only mild increases in prostate-specific antigen over control values Currently, insufficient evidence, primarily regarding psychologic safety and efficacy, exists to warrant general administration of testosterone to elderly hypogonadal men Further clinical investigations of this therapy in men with low testosterone levels and andropause symptoms are justified and necessary

Testosterone and andropause: the feasibility of testosterone replacement therapy in elderly men.

Relationship between patient variables and plasma clozapine concentrations: a dosing nomogram

Aggression and hostility in anabolic steroid users.

The serum anticholinergic activity (SAA) assay was originally designed to quantify the anticholinergic burden of drug exposure. The same assay has been used to measure the anticholinergic activity of standard drug solutions. There are limitations to the use of the assay in research and in applying these findings to clinical practice. Assays of standard drug solutions do not account for pharmacokinetic differences among drugs, which limits the interpretation of such measurements. In addition, emerging evidence has suggested that anticholinergic medications may not be the only cause of elevated SAA. Despite these limitations, elevated SAA has been consistently associated with cognitive impairment and delirium in a number of research settings. Such findings have prompted investigators to consider the potential application of the SAA assay in research and in clinical practice. Therefore, the objectives of this review are to summarize the current literature involving the SAA assay, describe the relative merits and shortfalls of the SAA assay as a research tool, and discuss the potential for use of the SAA assay as a clinical tool.

Paul J. Perry

Papers

Psychiatric Symptoms Associated with Anabolic Steroids: A Controlled, Retrospective Study

Testosterone and andropause: the feasibility of testosterone replacement therapy in elderly men.

Relationship between patient variables and plasma clozapine concentrations: a dosing nomogram

Aggression and hostility in anabolic steroid users.

A critical appraisal of the utility of the serum anticholinergic activity assay in research and clinical practice.