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

Insulinoma ‑ The incremental value of somatostatin receptor positron emission tomography Sir, The clinical diagnosis of hyperinsulinemic hypoglycemia is by itself difficult and most patients have a delayed diagnosis. In an adult, nondiabetic patient, insulinoma is the most common cause of hyperinsulinemic hypoglycemia. Furthermore, about 10% of insulinomas are believed to have already metastasized by the time they are diagnosed. Conventional imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) may not always be able to localize the lesions leading to further delay in definitive treatment that is surgical excision. Functional imaging has played an important role in lesion localization. Octreotide‑based tracers such as 111 In‑diethylenetriaminepentaacetic acid‑octreotide for planar and single‑photon emission computed tomography imaging were initially evaluated.

Insulinoma - The incremental value of somatostatin receptor positron emission tomography.

To conclude, effective management of hyperglycaemia, symptom control, and prevention of foot ulcers and infection through screening and surveillance remain mainstays of diabetic neuropathy management. Traditional and rational diabetic neuropathy treatments will be supplemented by novel cell based therapy and targeted drug delivery systems in the future.

Diabetic neuropathy: Part 2.

Insulin therapy too is acknowledged as an essential aspect of diabetes management, with unquestionable benefits. In spite of great strides in the manufacture, presentation and quality of this molecule, however, we have not achieved commensurable improvement in glycemic control. Data from across the world reports sub optimal control of persons started on insulin therapy. The best of randomized controlled trials and observational studies are unable to achieve target glycemic levels in all enrolled subjects. This happens in spite of aggressive treat to-target protocols used.

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Yashdeep Gupta

Papers

Insulinoma - The incremental value of somatostatin receptor positron emission tomography.

Diabetic neuropathy: Part 2.

Insulin and value-added therapy

Culture bound hypoglycemia symptomatology.

Pre-analytical factors in blood glucose measurement.