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 Clinical Efficacy Assessment Subcommittee of the American College of Physicians–American Society of Internal Medicine acknowledges the scientific validity of this product as a background paper and as a review that captures the levels of evidence in the management of patients with chronic stable angina as of November 17, 2002





The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines regularly reviews existing guidelines to determine when an update or a full revision is needed This process gives priority to areas in which major changes in text, and particularly recommendations, are merited on the basis of new understanding or evidence Minor changes in verbiage and references are discouraged

The ACC/AHA/American College of Physicians–American Society of Internal Medicine (ACP-ASIM) Guidelines for the Management of Patients With Chronic Stable Angina, which were published in June 1999, have now been updated The full-text guideline incorporating the updated material is available on the Internet (wwwaccorg or wwwamericanheartorg) in both a track-changes version showing the changes in the 1999 guideline in strike-out (deleted text) and highlighting …

https://cdr.lib.unc.edu/downloads/bz60cz34d

ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina)

Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes.

ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina).

Context.— Cardiac imaging has advanced rapidly, providing clinicians with several
 choices for evaluating patients with suspected coronary artery disease, but
 few studies compare modalities directly.
 Objectives.—
 To review the contemporary literature and to compare the diagnostic
 performance of exercise echocardiography (ECHO) and exercise single-photon
 emission computed tomography (SPECT) imaging in the diagnosis of coronary
 artery disease.
 Data Sources.—
 Studies published between January 1990 and October 1997 identified from
 MEDLINE search; bibliographies of reviews and original articles; and suggestions
 from experts in each area.
 Study Selection.—
 Articles were included if they discussed exercise ECHO and/or exercise
 SPECT imaging with thallous chloride TI 201 (thallium) or technetium Tc 99m
 sestamibi for detection and/or evaluation of coronary artery disease, if data
 on coronary angiography were presented as the reference test, and if the absolute
 numbers of true-positive, false-negative, true-negative, and false-positive
 observations were available or derivable from the data presented. Studies
 performed exclusively in patients after myocardial infarction, after percutaneous
 transluminal coronary angioplasty, after coronary artery bypass grafting,
 or with recent unstable coronary syndromes were excluded.
 Data Extraction.—
 Clinical variables, technical factors, and test performance were independently
 extracted by 2 reviewers on a standardized spreadsheet. Discrepancies were
 resolved by consensus.
 Results.—
 Forty-four articles met inclusion criteria. In pooled data weighted
 by the sample size of each study, exercise ECHO had a sensitivity of 85% (95%
 confidence interval [CI], 83%-87%) with a specificity of 77% (95% CI, 74%-80%).
 Exercise SPECT yielded a similar sensitivity of 87% (95% CI, 86%-88%) but
 a lower specificity of 64% (95% CI, 60%-68%). In a summary receiver operating
 characteristic model comparing exercise ECHO performance to exercise SPECT,
 exercise ECHO was associated with significantly better discriminatory power
 (parameter estimate, 1.18; 95% CI, 0.71-1.65), when adjusted for age, publication
 year, and a setting including known coronary artery disease for SPECT studies.
 In models comparing the discriminatory abilities of exercise ECHO and exercise
 SPECT vs exercise testing without imaging, both ECHO and SPECT performed significantly
 better than exercise testing. The incremental improvement in performance was
 greater for ECHO (3.43; 95% CI, 2.74-4.11) than for SPECT (1.49; 95% CI, 0.91-2.08).
 Conclusions.—
 Exercise ECHO and exercise SPECT have similar sensitivities for the
 detection of coronary artery disease, but exercise ECHO has better specificity
 and, therefore, higher overall discriminatory capabilities as used in contemporary
 practice.

/pdf/exercise-echocardiography-or-exercise-spect-imaging-a-meta-2083rtw08c.pdf

Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance

Background: Cardiovascular diseases are currently the most common cause of death worldwide and associated with significant impairment of quality of life (QOL). In this study, we aimed to evaluate the QOL patients with coronary heart disease (CHD) in our country and the factors associated with QOL in these patients. Materials and Methods: The study population was composed of 85 patients diagnosed with stable CHD. The data were collected using Ferrans and Powers’ Quality of Life Index Cardiac VersionIV and the query designed by the investigators. Results: Eighty-five patients (29 female, 56 male; ages between 38 and 72 years) were enrolled in this study. Married patients and those with greater incomes had greater QOL scores. Patients who had difficulties in daily works due to cardiac problems had lower QOL. Interestingly, patients with previous coronary intervention or surgey had similar QOL scores compared to those without. Patients who got emotional and social support had a greater social/economic score and who were able to get tangible social support had a higher global QOL score. Independent variables affecting the global QOL were marital and financial status, prior myocardial infarction (MI), and having difficulty in daily works. Conclusion: Marital and financial status, prior MI, and having difficulty in daily works are the main determinants for the QOL in patients with CHD. Social support may increase the effectiveness of their rehabilitation and psychosocial activity, thereby QOL. Effective public health interventions should be aimed at improving QOL, especially in the most vulnerable groups.

https://journals.tubitak.gov.tr/medical/issues/sag-09-39-3/sag-39-3-2-0901-26.pdf

Factors affecting quality of life in patients with coronary heart disease

Background
Extensively used lipid-lowering statins have also non-lipid-lowering, pleiotropic effects. Previous studies have demonstrated that a pre-procedural single dose of atorvastatin is associated with reduced peri-procedural myocardial injury.

Prevention of Peri-procedural Myocardial Injury Using a Single High Loading Dose of Rosuvastatin

Aim: Increased mean platelet volume (MPV) may reflect increased platelet activation and accepted as an independent coronary risk factor. Adrenergic system has effects on platelet activation and thrombocytopoiesis. In this study, we assessed the effects of autonomic nervous system activity on MPV in patients with acute myocardial infarction (MI). Materials and Methods: Forty-seven patients with acute anterior MI were compared with 32 patients having normal coronary arteries. All patients underwent heart rate variability analysis by 24-h holter monitoring and blood samples were taken for MPV measurements during day and night times during holter monitoring. Results: Mean heart rate (HR), Low frequency (LF), LF/High frequency (HF) ratio, MPV were higher, standard deviation of all NN intervals (SDNN), root mean square of successive differences (RMSSD), the number of NN intervals that differed by more than 50 ms from adjacent interval divided by the total number of all NN intervals (PNN50), HF and platelet counts were lower in the patients with anterior MI compared to the control group. Day time LF, LF/HF, and MPV were significantly higher and HF were significantly lower compared to those measured during night time in both groups. Pearson’s correlation analysis showed that MPV was positively correlated with ventricle score, degree of left anterior descending artery stenosis, mean HR, LF, LF/HF, and negatively correlated with SDNN, HF, and platelet count. Multivariate analysis revealed that MPV was affected by ventricle score and LF/HF ratio. Conclusions: MPV is significantly higher in the patients with MI and MPV in both groups shows great diurnal and nocturnal variation that is attributed to the alterations in the autonomic nervous system. We suggest that prognostic role of increased MPV in patients with MI are closely associated with increased sympathetic activity and decreased heart rate variability in these patients.

https://journals.tubitak.gov.tr/medical/issues/sag-09-39-2/sag-39-2-17-0901-13.pdf

Association between mean platelet volume and autonomic nervous system functions: Increased mean platelet volume reflects sympathetic overactivity

Objective In this study, we aimed at comparing the effects of standard once daily 20 mg atorvastatin treatment with that of atorvastatin 20 mg administered every other day on serum lipids and high sensitive C-reactive protein (hs-CRP) levels. Methods Sixty-one patients with serum total cholesterol levels of above 200 mg/dl and low density lipoprotein (LDL)--cholesterol levels of above 130 mg/dl were included in this prospective, randomized study. The patients were randomized into daily treatment of 20 mg atorvastatin (standard treatment) and 20 mg atorvastatin every other day (every other day treatment) groups. Before the treatment and at each visit, serum lipids and hs-CRP levels of all the patients were measured. Statistical analyses were performed Chi-square, unpaired t and two-way repeated measurements ANOVA tests. Results In the every other day treatment group, there was a 36.1% reduction in LDL-cholesterol levels by the end of first month (p 0.05). The LDL cholesterol levels of the group receiving 20 mg atorvastatin every day was reduced by %41 by the end of 1 month (p 0.05). Conclusions Alternate-day dosing of atorvastatin causes a significant lipid-lowering and antiinflammatory effects similar to that of daily administration and yet may provide some cost savings.

The comparison of the effects of standard 20 mg atorvastatin daily and 20 mg atorvastatin every other day on serum LDL-cholesterol and high sensitive C-reactive protein levels.

Background Mad honey intoxication occurs after ingestion of honey containing grayanotoxin. Case Report We report the case of a 36-year-old man who ingested mad honey and developed atrial fibrillation. Discussion Mad honey intoxication is often characterized by symptoms such as hypotension, bradycardia, and syncope. Patients may also experience gastrointestinal, neurologic, and cardiovascular symptoms due to intoxication. Cardiac rhythm abnormalities, including sinus bradycardia, atrioventricular blocks, and nodal rhythms, also may be observed. To our knowledge, this is the first case report of a 36-year old man developing atrial fibrillation with a slow ventricular response after mad honey ingestion.

Tahir Durmaz

Papers

Factors affecting quality of life in patients with coronary heart disease

Prevention of Peri-procedural Myocardial Injury Using a Single High Loading Dose of Rosuvastatin

Association between mean platelet volume and autonomic nervous system functions: Increased mean platelet volume reflects sympathetic overactivity

The comparison of the effects of standard 20 mg atorvastatin daily and 20 mg atorvastatin every other day on serum LDL-cholesterol and high sensitive C-reactive protein levels.

A Rare Cause of Atrial Fibrillation: Mad Honey Intoxication