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 AUDIT Alcohol Consumption Questions (AUDIT-C) An Effective Brief Screening Test for Problem Drinking

This Pulse Check is a report of national trends in illicit drug abuse and drug markets in the United States. The report draws on conversations with ethnographers and epidemiologists working in the drug field, law enforcement agents, and drug treatment providers across the United States. Information from each of these sources is summarized in narrative form broken down by drug type and presented in detailed tables at the end of the report. The four groupings of drugs are heroin, cocaine, marijuana, and emerging drugs. Results show that the market for heroin and cocaine remains fairly stable. Marijuana continues to be popular among young people and is frequently used with alcohol, hallucinogens, cocaine, or methamphetamines. Among the emerging drugs, methamphetamine continues to be a problem in the West and parts of the South, its low price making it an easily accessible drug. "Club drugs," such as Lysergic Acid Diethylamide (LSD) and Ketamine, are part of the drug scene in most areas, with many young people using a combination of these substances. (RJM) ******************************************************************************** Reproductions supplied by EDRS are the best that can be made from the original document. ******************************************************************************** Office of National Drug Control Policy PULSE CHECK National Trends in Drug Abuse Executive Office of the President Office of National Drug Control Policy Barry R. McCaffrey, Director

Office of national drug control policy

Profound and debilitating fatigue is the most common complaint reported among individuals with autoimmune disease, such as systemic lupus erythematosus, multiple sclerosis, type 1 diabetes, celiac disease, chronic fatigue syndrome, and rheumatoid arthritis. Fatigue is multi-faceted and broadly defined, which makes understanding the cause of its manifestations especially difficult in conditions with diverse pathology including autoimmune diseases. In general, fatigue is defined by debilitating periods of exhaustion that interfere with normal activities. The severity and duration of fatigue episodes vary, but fatigue can cause difficulty for even simple tasks like climbing stairs or crossing the room. The exact mechanisms of fatigue are not well understood, perhaps due to its broad definition. Nevertheless, physiological processes known to play a role in fatigue include oxygen/nutrient supply, metabolism, mood, motivation, and sleepiness—all which are affected by inflammation. Additionally, an important contributing element to fatigue is the central nervous system—a region impacted either directly or indirectly in numerous autoimmune and related disorders. This review describes how inflammation and the central nervous system contribute to fatigue and suggests potential mechanisms involved in fatigue that are likely exhibited in autoimmune and related diseases.

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Fatigue, Sleep, and Autoimmune and Related Disorders

Young adults starting college or university education encounter multiple stressors related to transitional life-stage and novel environments. Current studies reveal high rates of symptoms related to common mental health problems like depression, anxiety and stress. However, limited knowledge exists on the determinants on these problems among Canadian students. The primary aim of the study was to investigate the impact of contextual determinants, as perceived by students, on self-reported mental health, and how these impacts varied by depression, anxiety and stress. A cross-sectional survey was conducted with students attending a large university in Toronto, Canada. Participants completed a self-administered online questionnaire as part of a larger project. The questions asked about contextual determinants related to personal, interpersonal, family, social, socio-economic and political factors along with levels of depression, anxiety and stress as measured by Patient Health Questionnaire-9, Beck Anxiety Inventory and Perceived Stress Scale. A total of 148 students completed the questionnaire (37 males and 111 females) with an age range of 19–54 years (median 22, IQR 21–24.8). English was reported as first language by 62.8% while 34.5% self-identified as white and 58.1% reported being born in Canada. Overall, 39.5% reported symptoms of moderate to severe depression, 23.8% reported moderate–severe anxiety and 80.3% reported moderate–severe levels of perceived stress, with no significant differences between males and females. In the final multivariate analysis, variables significantly associated with depression were grade-point-average (aOR 2.46, 95% CI 1.017–5.97), family factors (aOR 3.46, 95% CI 1.50–7.94), social factors (aOR 3.24, 1.30–8.1), self-rated health (aOR 0.34, 95% CI 0.14–0.82) and political factors (aOR 0.40, 95% CI 0.16–0.97). Anxiety was significantly associated with family factors (aOR 2.79, 1.09–7.18), socioeconomic factors (aOR 2.59, 95% CI 1.05–6.42) and age (aOR 0.33, 95% CI 0.11–0.98). The significant factors for stress were grade-point-average (aOR 2.41, 1.01–5.75) and social factors (aOR 3.87, 95% CI 1.59–9.43). The study found strong to moderate impact of several determinants on depression, anxiety and stress. The results suggest a need to address a variety of factors affecting students’ mental health. Trial registration Parent trial: http://www.isrctn.com/ISRCTN92827275

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Perceived impact of contextual determinants on depression, anxiety and stress: a survey with university students

One in five young adults are diagnosed with a mental illness and many experience psychological distress during their first year of college due to new pressures in academia. The purpose of the current integrative review was to describe and synthesize hope and mental health in young adults in college. PubMed, CINAHL, and PsycINFO were searched for articles published in peer-reviewed journals from 2011-2016. Twenty empirical works were selected for inclusion and five themes emerged: (a) Hope is Associated With Improved Coping, (b) Hope is Associated With Improved Well-Being, (c) Hope is a Moderator Between Depression and Negative Life Events, (d) Hope is a Protective Factor in Suicide, and (e) Hope is a Factor in Healthy Behavior Engagement. Hope may be a protective factor in suicide and negative, self-deprecatory thinking. Further research is needed to determine if increasing hope in young adult college students will decrease the risk of suicide and non-suicidal self-injury, increase healthy behavior engagement, and improve coping and well-being. [Journal of Psychosocial Nursing and Mental Health Services, 55(2), 28-35.].

Hope and Mental Health in Young Adult College Students: An Integrative Review.

The Role of Hope for Adolescents with a Chronic Illness: An Integrative Review

A systematic review and meta-analysis of behavioral sleep interventions for adolescents and emerging adults.

Purpose The aim of this review was to integrate empirical and theoretical literature on fatigue among adults with type 1 diabetes mellitus (T1DM). A methodological review using an integrative approach was used. Databases MEDLINE via Pubmed, CINAHL, PsycINFO, and Science Direct were searched for peer-reviewed articles published in English from 2007-2017, using the following search terms and Boolean operators: "Type 1 Diabetes" and "Fatigue." Of 199 articles initially retrieved, 14 were chosen for inclusion. These articles included 13 quantitative (7 cross-sectional, 2 cohort, 2 secondary data analyses, 2 experimental) and 1 qualitative phenomenology. Fatigue was identified as one of the most troublesome symptoms reported in persons with T1DM. Four main themes emerged: fatigue in T1DM is multidimensional and related to psychological, physiological, situational, and sociodemographic factors. Conclusions Fatigue is considered a classic symptom of hyperglycemia; however, there were minimal data to support the theory that fatigue is related to hyperglycemia or hypoglycemia. Studies on fatigue among persons with T1DM are limited to small samples and cross-sectional designs with few randomized controlled trials addressing fatigue and diabetes-related symptoms. Evidence is conflicting regarding the onset of fatigue among persons with T1DM and the relationship between fatigue and diabetes duration. The prevalence of fatigue is likely influenced by disease physiology, psychological stress, and lifestyle factors, but more research is needed to confirm these relationships as causal inference is unclear.

Fatigue Among Adults With Type 1 Diabetes Mellitus and Implications for Self-Management: An Integrative Review.

OBJECTIVE We used multilevel models (MLMs) to determine person (between-persons) and day level (within-person) associations between glucose variability indices and sleep characteristics in adolescents with type 1 diabetes (T1D). METHODS Adolescents with T1D (Mean age 13.4 ± 1.8 years; 37.8% male; mean HbA1c 8.2 ± 1.2%, 66 mmol/mol) monitored their sleep and glucose patterns concurrently for 3-7 days with a wrist actigraph on their non-dominant wrist and a continuous glucose monitor (CGM) (their own or a provided, blinded CGM). Glucose variability indices included J index, coefficient of variation, low and high blood glucose risk indices (LBGI and HBGI), time in range, and sleep characteristics, including bedtime, wake time, total sleep time, sleep efficiency, wake after sleep onset, awakenings, and sleep fragmentation index. RESULTS More overall glucose variability was associated within person, more sleep disruptions (more awakenings and more fragmentation) or poorer sleep in our study (earlier wake time or longer wake after sleep onset). Also, more time spent in hypoglycemia <70 mg/dL and a higher LBGI was associated within person with earlier wake time indicating poorer sleep. However, a lower LBGI was associated with a later between-persons wake time. CONCLUSIONS Monitoring over a longer period of time in subsequent studies would allow researchers to determine the within person association between habitual short sleep duration and glucose variability. Providers should regularly assess sleep habits in adolescents as a way to improve glycemic control. Targeting a euglycemic range overnight is also important to promote better sleep and to decrease sleep disruptions.

Stephanie Griggs

Papers

Hope and Mental Health in Young Adult College Students: An Integrative Review.

The Role of Hope for Adolescents with a Chronic Illness: An Integrative Review

A systematic review and meta-analysis of behavioral sleep interventions for adolescents and emerging adults.

Fatigue Among Adults With Type 1 Diabetes Mellitus and Implications for Self-Management: An Integrative Review.

Daily variations in sleep and glucose in adolescents with type 1 diabetes.