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

1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

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Hyperglycemia and Adverse Pregnancy Outcomes

Metformin is a widely-used drug that results in clear benefits in relation to glucose metabolism and diabetes-related complications. The mechanisms underlying these benefits are complex and still not fully understood. Physiologically, metformin has been shown to reduce hepatic glucose production, yet not all of its effects can be explained by this mechanism and there is increasing evidence of a key role for the gut. At the molecular level the findings vary depending on the doses of metformin used and duration of treatment, with clear differences between acute and chronic administration. Metformin has been shown to act via both AMP-activated protein kinase (AMPK)-dependent and AMPK-independent mechanisms; by inhibition of mitochondrial respiration but also perhaps by inhibition of mitochondrial glycerophosphate dehydrogenase, and a mechanism involving the lysosome. In the last 10 years, we have moved from a simple picture, that metformin improves glycaemia by acting on the liver via AMPK activation, to a much more complex picture reflecting its multiple modes of action. More work is required to truly understand how this drug works in its target population: individuals with type 2 diabetes.

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The mechanisms of action of metformin

https://www.thieme-connect.de/products/ejournals/pdf/10.4103/2321-0656.120281.pdf

Children with diabetes friendly services: A blueprint

WITHDRAWN: Protective effect of Emblica officinalis fruit extract on cisplatin-induced nephrotoxicity in female rats

This article is the second in the series of Addressing Insulin Misperceptions (AIM). It structures perceived objections to insulin according to those prevalent at initiation and intensification, and suggests specific interventions for the commonly encountered misperceptions. The article reflects the need for dialogue in the diabetes clinic: a careful history-taking, involving focused listening, will help identification of misperceptions, and allow crafting of an appropriate strategy to dispel them.

Addressing Insulin Misperceptions (AIM) - Part 2.

Keeping in mind these factors, we feel that a home visit by the outreach worker may help in identifying additional women with t2DM and at risk for this disease. the ADA hbA1c high-risk cutoff of 39 mmol/mol yielded sensitivity of 45 % and specificity of 84 % for identifying women with abnormal glucose tolerance in AtLANtIC-DIP study [4]. thus, home sampling using hbA1c will help in identifying nearly 50 % of additional women out of those who are not able to attend postpartum screening despite periodic reminders. the advantage of hbA1c is that it does not put constraint on the patient or health-care worker to collect a fasting or early morning sample. taking a step further, the utility of self administered OGtt should also be studied in women, who have normal hbA1C [5]. this is especially important for Asians, who may have only abnormal 2 hr value on OGtt [6]. though reaching out women may be a costly affair in regions with low-density population, it could prove to be a highly cost-effective strategy in regions with high-density population. these strategies, if found cost-effective and feasible, could further be linked to existing national programmes of countries, where contacts are made with the patient after delivery in some form or the other, like infant immunization at regular intervals. It should be remembered that screening is not an aim or an endpoint; rather, it is a means or a strategy of limiting disease and its negative impact on the concerned individual, as well as society. While treatment of disease may belong to the corridors of hospitals, screening has to go beyond the ivory towers of modern medicine. We must remember that we have achieved success in smallpox and polio eradication, because health care reached the community’s doorsteps, not because the community came to us. Sir,

Improving postpartum screening rates.

A recent example is the finding of increased risk of hospitalization in patients randomized to saxagliptin, as reported by the saxagliptin assessment of vascular outcomes recorded in patients with diabetes mellitus–thrombolysis in myocardial infarction (SAVOR‐TIMI) 53 trial.[1] This unexpected result, which stemmed from analysis of one component of a secondary endpoint, has attracted more debate than the primary end point results, which showed that saxagliptin neither increased nor decreased the rate of ischemic events in persons with type 2 diabetes. No reason has been found so far to explain the association between saxagliptin and hospitalization. Results from the Vildagliptin in Ventricular Dysfunction Diabetes (VIVIDD) study regarding the effect of vildagliptin on cardiac function are also open to interpretation.[2]

Yashdeep Gupta

Papers

Children with diabetes friendly services: A blueprint

WITHDRAWN: Protective effect of Emblica officinalis fruit extract on cisplatin-induced nephrotoxicity in female rats

Addressing Insulin Misperceptions (AIM) - Part 2.

Improving postpartum screening rates.

Can cardiac autonomic neuropathy be a predictor of cardiovascular outcomes in diabetes