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

Background 
Adverse drug reactions in children are an important public health problem. We have undertaken a systematic review of observational studies in children in three settings: causing admission to hospital, occurring during hospital stay and occurring in the community. We were particularly interested in understanding how ADRs might be better detected, assessed and avoided.


Methods and Findings 
We searched nineteen electronic databases using a comprehensive search strategy. In total, 102 studies were included. The primary outcome was any clinical event described as an adverse drug reaction to one or more drugs. Additional information relating to the ADR was collected: associated drug classification; clinical presentation; associated risk factors; methods used for assessing causality, severity, and avoidability. Seventy one percent (72/102) of studies assessed causality, and thirty four percent (34/102) performed a severity assessment. Only nineteen studies (19%) assessed avoidability. Incidence rates for ADRs causing hospital admission ranged from 0.4% to 10.3% of all children (pooled estimate of 2.9% (2.6%, 3.1%)) and from 0.6% to 16.8% of all children exposed to a drug during hospital stay. Anti-infectives and anti-epileptics were the most frequently reported therapeutic class associated with ADRs in children admitted to hospital (17 studies; 12 studies respectively) and children in hospital (24 studies; 14 studies respectively), while anti-infectives and non-steroidal anti-inflammatory drugs (NSAIDs) were frequently reported as associated with ADRs in outpatient children (13 studies; 6 studies respectively). Fourteen studies reported rates ranging from 7%–98% of ADRs being either definitely/possibly avoidable.


Conclusions 
There is extensive literature which investigates ADRs in children. Although these studies provide estimates of incidence in different settings and some indication of the therapeutic classes most frequently associated with ADRs, further work is needed to address how such ADRs may be prevented.

Adverse Drug Reactions in Children—A Systematic Review

Therapeutics and clinical risk management

http://bjp.rcpsych.org/content/122/567/230.3.full.pdf

DRUGS: International Drug Monitoring: The Role of National Centres.

Summary
Background: India has witnessed a rapidly exploding epidemic of diabetes in recent years and currently leads the world with the largest number of diabetic subjects in a single country. World Health Organization estimates that in 2000, 31·7 million individuals were affected by diabetes in India and these numbers will rise to 79·4 millions by the year 2030. In view of the above situation, drug utilization review of antidiabetic medicines in Indian healthcare settings has a valid significance to promote rational drug use in diabetics.

Objective:  The present study is aimed to determine the drug utilization patterns in type 2 diabetic patients on oral hypoglycemic agents in the Medicine Outpatient Department (OPD) and Inpatient Department (IPD) of Majeedia Hospital, a teaching hospital of Hamdard University, New Delhi.

Methods:  Patients with established type 2 diabetes (n = 218) visiting the OPD and IPD were interviewed using a structured questionnaire during the period January–May 2006.

Results:  A majority of the type 2 diabetic patients in this setting were treated with multiple antidiabetic drug therapy. The most commonly prescribed antidiabetic drug class was biguanides (metformin) followed by sulphonylureas (glimepiride), thiazolidinediones (pioglitazone), insulin and alpha-glucosidase inhibitors (miglitol). As monotherapy insulin was the most common choice followed by metformin. The most prevalent multiple therapy was a three-drug combination of glimepiride + metformin + pioglitazone. More than half of the type 2 diabetic patients showed poor adherence (compliance) to the prescribed therapy.

Conclusion:  This study strongly highlights the need for patient education or counselling on use of antidiabetic and concomitant drugs, monitoring of blood glucose and glycosylated haemoglobin (HbA1c) levels, diet control, and correction of diabetic complications. Metabolic control was poor and HbA1c monitoring was underutilized. Clinical monitoring of patients’ adherence to prescribed treatments is recommended and measures should be taken to improve it.

Drug utilization of oral hypoglycemic agents in a university teaching hospital in India

Background : The choice of antimicrobial therapy for bloodstream infections is often empirical and based on the knowledge of local antimicrobial activity profiles of the most common bacteria causing such infections. Aims : The present study was aimed to investigate frequency of bacterial pathogens causing septicemia and their antimicrobial resistant pattern in hospital admitted patients. Settings and Design : It was a prospective study, conducted at Majeedia Hospital, Hamdard University, New Delhi, India. Material and Methods : We examined prospectively, 168 bacterial strains isolated from 186 clinically diagnosed septicemia cases admitted at a University Hospital in New Delhi, over a period of six months from July 2009 to December 2009. Antimicrobial susceptibility was performed according to Clinical and Laboratory Standards Institute (CLSI, USA) guidelines. Results : The most frequently identified Gram-positive bacteria were coagulase-negative staphylococci 63.5%, Staphylococcus aureus 23.1%, enterococci 5.8% and alpha-haemolytic streptococci 5.8%. The most frequently Gram-negative bacteria identified were Acinetobacter species 31%, Salmonella typhi 24.1%, Escherichia coli 23.3% and Pseudomonas aeruginosa 13.8%. Coagulase-negative staphylococci showed maximum resistance to cefaclor 57.1% and ampicillin 46.9%. Staphylococcus aureus showed maximum resistance to amoxicillin 100% and ampicillin 91.7%. Acinetobacter species showed maximum resistance to amoxicillin 89.7%, amoxiclav 87.1% and ampicillin 85.7%. Salmonella typhi, Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumoniae showed maximum resistance to ampicillin, 46.4%, 92%, 93.8% and 100%, respectively. Conclusions : Gram-negative pathogens predominated in bloodstream infections. Resistance to most of the antimicrobial agents for a number of pathogens implicated in bloodstream infections, especially in Gram-negative bacteria, has reached worrisome levels and continues to increase.

Resistant patterns of bacteria isolated from bloodstream infections at a university hospital in Delhi.

The aim of the present study was to monitor adverse drug reactions (ADRs) in the Medicine out patient department (OPD) of a University Teaching Hospital.Method: A prospective evaluation of the ADRs reported in the Department of Medicine of our University Teaching Hospital over a period of 4-months was conducted.Results: During the study period, a total of 600 patients visited the Medicine OPD and 122 ADRs were reported.  Out of 122 reports that were identified, a higher percentage of ADRs in males (52.4%) was observed as compared to females (47.5%). Of the 122 ADRs, 50 were found to be mild (41.0%), 49 moderate (40.2%), and 23 severe (18.2%). A total of 71 (58.0%) ADRs were observed in patients receiving 4 or more medications concurrently. Conversely 46 (37.7%) ADRs were detected in patients using 3 or less medicines. The largest number of reports were associated with antihypertensive therapy (39.3%), followed by antimicrobials (31.1%) and antidiabetics (10.7%). Amongst the organ systems affected, gastrointestinal ADRs constituted a major component (24.7%) followed by skin reactions (22.2%). On causality assessment, nearly 29.5% ADRs were considered as probable, 33.6% possible and 6.6% could not be categorised and were placed under unassessable.Conclusion: The present work is the maiden pharmacovigilance study conducted at our university teaching hospital. The data presented here will be useful in future, long term and more extensive ADR monitoring in the hospital and in promotion of rational prescribing and drug use in the hospital.

https://scielo.isciii.es/pdf/pharmacy/v5n1/046-049.pdf

A pharmacovigilance study in the department of medicine of a university teaching hospital

Orlistat is recommended in the treatment of obesity, which is an independent risk factor for nonalcoholic fatty liver disease (NAFLD). The reported findings of orlistat in NAFLD are divisive. Recently, periostin is identified as an important regulatory molecule in the pathogenesis of obesity-induced fatty liver. Therefore, this study aimed to evaluate the potential effects of orlistat in the treatment of NAFLD. A 16-week prospective observational study was conducted, with obese NAFLD patient (n=77) receiving orlistat (120 mg capsules, three times a day) with hypocaloric diet or hypocaloric diet only. Grades of fatty liver were determined using ultrasound (US) echogenicity of liver; serum levels of periostin, adiponectin, tumor necrosis factor (TNF)-α and interleukin-6 were determined using ELISA kits at 0 and 16 weeks. Correlations of US grades of fatty liver with these biomarkers were also determined. Orlistat significantly reversed the US grades of fatty liver (P=0.016), decreased serum levels of periostin (P=0.030) and TNF-α (P=0.040), and increased serum adiponectin levels (P<0.001) when compared with hypocaloric diet only. Serum interleukin-6 levels were not found to be significantly different in both groups after the treatment. In the orlistat group, the degree of reduction in grades of fatty liver was found to be positively correlated with the changes in serum levels of periostin (rs=0.306, P=0.041) and adiponectin (rs=0.314, P=0.036), whereas the associations were insignificant with the change in serum levels of TNF-α (rs=0.053, P=0.729). Mild gastrointestinal side effects (20%) were reported in the orlistat group. In conclusion, orlistat is effective in the treatment of NAFLD patients without fibrosis. This study demonstrated a positive association between the reduction of fatty infiltration in the liver and the changes in serum levels of periostin and adiponectin in obese NAFLD patients.

/pdf/effect-of-orlistat-on-periostin-adiponectin-inflammatory-khwlp03tba.pdf

Effect of orlistat on periostin, adiponectin, inflammatory markers and ultrasound grades of fatty liver in obese NAFLD patients

Aim
To monitor the adverse drug reactions (ADRs) caused by antihypertensive medicines prescribed in a university teaching hospital.

/pdf/monitoring-of-adverse-drug-reactions-associated-with-2tuhzy6an1.pdf

Prem Kapur

Papers

Drug utilization of oral hypoglycemic agents in a university teaching hospital in India

Resistant patterns of bacteria isolated from bloodstream infections at a university hospital in Delhi.

A pharmacovigilance study in the department of medicine of a university teaching hospital

Effect of orlistat on periostin, adiponectin, inflammatory markers and ultrasound grades of fatty liver in obese NAFLD patients

Monitoring of adverse drug reactions associated with antihypertensive medicines at a university teaching hospital in New Delhi