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

Icmje

Potentially inappropriate prescribing (PIP) is one of the main risk factors for adverse drug events (ADEs) in older people. This systematic literature review aims to determine prevalence and type of PIP in community-dwelling older people across Europe, as well as identifying risk factors for PIP. The PubMed and Web of Science database were searched systematically for relevant manuscripts (January 1, 2000–December 31, 2014). Manuscripts were included if the study design was observational, the study participants were community-dwelling older patients in Europe, and if a published screening method for PIP was used. Studies that focused on specific pathologies or that focused on merely one inappropriate prescribing issue were excluded. Data analysis was performed using R statistics. Fifty-two manuscripts were included, describing 82 different sample screenings with an estimated overall PIP prevalence of 22.6 % (CI 19.2–26.7 %; range 0.0–98.0 %). Ten of the sample screenings were based on the Beers 1997 criteria, 19 on the Beers 2003 criteria, 14 on STOPP criteria (2008 version), 8 on START-criteria (2008 version), and 7 on the PRISCUS list. The 24 remaining sample screenings were carried out using compilations of screening methods or used country-specific lists such as the Laroche criteria. It appears that only PIP prevalence calculated from insurance data significantly differs from the other data collection method categories. Furthermore, risk factors most often positively associated with PIP prevalence were polypharmacy, poor functional status, and depression. Drug groups most often involved in PIP were anxiolytics (ATC-code: N05B), antidepressants (N06A), and nonsteroidal anti-inflammatory and anti-rheumatic products (M01A). PIP prevalence in European community-dwelling older adults is high and depends partially on the data collection method used. Polypharmacy, poor functional status, and depression were identified as the most common risk factors for PIP.

Potentially inappropriate prescribing in community-dwelling older people across Europe: a systematic literature review

Potentially inappropriate prescribing (IP) is an issue of major importance in the pharmacotherapy of older people globally. To date, Beers’ criteria have been in common research usage for defining potentially inappropriate medications (PIMs) in older people. However, Beers’ criteria have a number of serious flaws and are of doubtful relevance to routine geriatric pharmacotherapy. For these reasons, new geriatric IP criteria have been devised and validated, called screening tool of older persons’ prescriptions (STOPP) and screening tool to alert to right treatment (START) for detection of potential errors of prescribing commission and omission. Prevalence studies in older people in southern Ireland show substantial rates of prescription of one or more PIMs in the primary care setting (22%), in acute hospital care (35%) and in nursing home care (60%) using STOPP criteria. Similarly, prevalence rates of potentially serious prescribing omission are high both in hospital (58%) and in primary care (23%). Prospective data show that STOPP criteria detect adverse drug effects (ADEs) that are causal or contributory to acute hospitalisation in older people 2.8 times more frequently than Beers’ criteria. This suggests that ADEs are likely associated with PIMs in older people, contrary to recent research data showing no significant association on the basis of defining PIMs using Beers’ criteria. We have recently shown that STOPP/START criteria as an intervention significantly improves medication appropriateness in hospitalised older people. Whether STOPP/START can prevent ADEs and reduce drug costs remains to be elucidated by means of further randomised controlled trials.

Iconography : STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age

Background: Studies have reported the presence of sleep disorders in approximately 50-70% of diabetic patients, and these may contribute to poor glycemic control, diabetic neuropathy, and overnight hypoglycemia. The aim of this study was to determine the frequency of sleep disorders in diabetic patients, and to investigate possible relationships between scores of these sleep disorders and obstructive sleep apnea syndrome (OSAS) and diabetic parameters (fasting blood glucose, glycated hemoglobin A1c [HbA1c], and lipid levels). Methods: We used the Berlin questionnaire (BQ) for OSAS, the Epworth Sleepiness Scale (ESS), and the Pittsburgh Sleep Quality Index (PSQI) to determine the frequency of sleep disorders and their possible relationships with fasting blood glucose, HbA1c, and lipid levels. Results: The study included 585 type 2 diabetic patients admitted to family medicine clinics between October and December 2014. Sleep, sleep quality, and sleep scores were used as the dependent variables in the analysis. The ESS scores showed that 54.40% of patients experienced excessive daytime sleepiness, and according to the PSQI, 64.30% experienced poor-quality sleep. The BQ results indicated that 50.20% of patients were at high-risk of OSAS. HbA1c levels correlated significantly with the ESS and PSQI results ( r = 0.23, P r = 0.14, P = 0.001, respectively), and were significantly higher in those with high-risk of OSAS as defined by the BQ ( P Conclusions: Sleep disorders are common in diabetic patients and negatively affect the control of diabetes. Conversely, poor diabetes control is an important factor disturbing sleep quality. Addressing sleep disturbances in patients who have difficulty controlling their blood glucose has dual benefits: Preventing diabetic complications caused by sleep disturbance and improving diabetes control.

Effects of Sleep Disorders on Hemoglobin A1c Levels in Type 2 Diabetic Patients.

Objective: Our aim was to adapt for Turkish and perform the reliability study of The Patient Health Questionnaire-9 (PHQ-9).
Material and methods: PHQ-9 was translated to Turkish by three researchers and a consensus meeting was held after the translation process. Turkish text on which the researchers agreed was translated into English by an independent professional translator. As a result of this process, the researchers obtained the final version on which they agreed and the accuracy of which was proved by back translation.
Results: The questionnaire was administered to patients above 18 years presenting to Family Medicine clinic. Total of 96 patients (42 male 54 female, with an average age of 37.63 ± 11.66 years) took part in this study. Turkish version of the questionnaire was found to be quite reliable. (Cronbach’s alpha 0.842)
Conclusion: Turkish version of The Patient Health Questionnaire-9 is quite reliable. We believe that this questionnaire may be used for objective assessment of diagnosing depression, evaluating its severity and its follow-up in clinical practice.

/pdf/turkish-reliability-of-the-patient-health-questionnaire-9-19s4mu3xz9.pdf

Turkish reliability of the patient health questionnaire-9

Aim. Our aim was to detect older patients who were prescribed inappropriate drugs according to START/STOPP criteria in primary care. Materials and Method. Patients aged over 65, admitted to health center no. 5 in Afyon, were included. The files of the subjects were surveyed retrospectively for the final one year in the digital environment, using the Family Medicine Information System. The files surveyed allowed us to list the drugs they used in the past year and to detect inappropriate drug use. Results. The number of patients that took part in this study was 325 (average age: <path id="x33" d="M285 378v-2q65 -13 102 -54.5t37 -97.5q0 -57 -30.5 -104.5t-74 -75t-85.5 -42t-72 -14.5q-31 0 -59.5 11t-40.5 23q-19 18 -16 36q1 16 23 33q13 10 24 0q58 -51 124 -51q55 0 88 40t33 112q0 64 -39 96.5t-88 32.5q-29 0 -64 -11l-6 29q77 25 118 57.5t41 84.5
q0 45 -26.5 69.5t-68.5 24.5q-67 0 -120 -79l-20 20l43 63q51 56 127 56h1q66 0 107 -37t41 -95q0 -42 -31 -71q-22 -23 -68 -54z" /> <path id="x36" d="M137 343l67 33q37 17 63 17q79 0 129.5 -53t50.5 -131q0 -92 -58 -156.5t-147 -64.5t-147 68t-58 182q0 63 17 119t43 95.5t61.5 72t69 52t67.5 31.5q62 22 128 33l6 -32q-56 -11 -108 -35q-149 -71 -184 -231zM227 337q-47 0 -95 -27q-6 -23 -6 -70q0 -93 36 -155.5
t96 -62.5q53 0 78 45.5t25 105.5q0 68 -35 116t-99 48z" /> years). We found that, among these participants, 48 patients (14.8%) were using drugs inappropriately according to STOPP criteria. Conclusion. Further focus on avoiding inappropriate drug use will allow clinicians and other health professionals to reduce side effects and other complications. In patients aged over 65, there is a need to attach particular importance to inappropriate drug use, drug interactions, and avoidance of side effects.

/pdf/the-use-of-start-stopp-criteria-for-elderly-patients-in-c8lisd16qz.pdf

The Use of START/STOPP Criteria for Elderly Patients in Primary Care

Objective: The main goal of chronic kidney disease (CKD) treatment is the prevention of progression of the disease and complications. Inappropriate drug use in patients with CKD is an important issue, which may cause adverse effects on patients and progression of chronic renal failure. The aim of this study is to find the rate of inappropriate drug use among CKD patients. Methods: The subjects of this study were selected from the patients with a CKD history of minimum one year, who did not receive renal replacement therapy. Patients were asked to provide a digital record of the drugs they used over the last one year. Individually, for each patient, the drugs that may be contraindicative and that require dose adjustment were identified based on glomerular filtration rate (GFR). Results: This study includes a total of 185 participants – 97 female (52.4%) and 88 male (47.6%) patients. The average age of patients was 60.50 ± 14.56. It was shown that 149 patients (80.5%) were using inappropriate drugs....

Inappropriate use of nonsteroidal anti-inflammatory drugs and other drugs in chronic kidney disease patients without renal replacement therapy

Aim : In this study, our aim is to evaluate the insulin resistance and quality of life in obese subjects and nonobese subjects and to find out the Vitamin D (VD) status and correlations between obesity and control groups and also according to their quality of life scores. Materials and Method : The study was carried out between May and October 2013 which is the period of VD synthesis in Turkey. The participants of this study were volunteering individuals – obese and nonobese individuals defined according to the body mass index (BMI) – that did not receive any VD support in the last 1‑year and did not have any known chronic diseases. 1,25‑OH VD status and homeostatic model assessment insulin resistance (HOMA‑IR) values were evaluated. Results : The study population consisted of 39 individuals with normal weight (23 women, 16 men) and 66 individuals categorized as obese (51 women, 15 men). The difference in HOMA‑IR and VD values between the group of obese individuals and the group of nonobese individuals was significant (P < 0.001 vs. P <0.001). The median value of HOMA‑IR was higher in the obese group than in the nonobese group (P < 0.001) while the median value of VD was higher in the nonobese group than in the obese group (P < 0.001). The results regarding the relationship of BMI with HOMA‑IR and VD show that there was a positive correlation between HOMA‑IR and BMI (rs = 0.507; P < 0.001) and there was a negative correlation between HOMA‑IR and VD (rs = −0.316; P = 0.0001). Conclusion : Given serious diseases associated with low serum VD levels such as diabetes and cardiovascular disorders as well as low side effect incidence and low cost of VD treatment, it would be a reasonable approach to identify routine serum 25(OH) D and/or 1,25‑OH VD levels of obese patients and administer a treatment to patients with low levels of VD. Key words : 1,25‑OH Vitamin D, insulin resistance, obesity

/pdf/relationship-between-1-25-dihydroxy-vitamin-d-levels-and-3vdw439io6.pdf

Ugur Bilge

Papers

Effects of Sleep Disorders on Hemoglobin A1c Levels in Type 2 Diabetic Patients.

Turkish reliability of the patient health questionnaire-9

The Use of START/STOPP Criteria for Elderly Patients in Primary Care

Inappropriate use of nonsteroidal anti-inflammatory drugs and other drugs in chronic kidney disease patients without renal replacement therapy

Relationship between 1,25-dihydroxy Vitamin D levels and homeostatic model assessment insulin resistance values in obese subjects.