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

COVID-19 Dashboard

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.

/pdf/the-mechanisms-of-action-of-metformin-3fa1vov0hg.pdf

The mechanisms of action of metformin

Metabolic Syndrome is matched by an equally large number of definitions, monikers, and acronyms. Known by various names such as the Deadly Quartet, Dysmetabolic Syndrome, hypertriglyceridaemic waist, insulin resistance syndrome, Syndrome W, Syndrome X, and Reaven's Syndrome, the concept describes a constellation of clinical features which increase the risk of cardiovascular disease.1 In some parts of the world, apronyms have been coined to facilitate understanding of these features. CHAOS, for example used in Australia, lists five characteristics of cardiovascular dysmetabolism: Coronary artery disease, Hypertension, Atherosclerosis, Obesity, and Stroke.2

Metabolic Syndrome: The drums are beating.

The guru–shishya (teacher–disciple or mentor–mentee) relationship has been the basis of medical education since ancient times. With the help of modern communication technology, our Dronacharyas now are able to connect with multiple shishyas. Thus, they can mentor not only the few Arjunas working with them, but also countless Eklavyas, practising in remote locations, bereft of expert guidance and support. One way of reaching out to the physician community is through guidelines. Mishra and Chaturvedi provide a comprehensive overview of the need for India-specific guidelines, and suggest ways of maximizing their impact. We concur with their views and strengthen their argument as follows.

My name is Eklavya: Indian guidelines are necessary.

Objectives This is a diagnostic test research study to evaluate the various existing methods of thyroid examination and their comparison with the novel modified Rose method. It also aims to measure inter-examiner variation in clinical findings based on the level of education and training, as compared to ultrasonography. Methodology This cross-sectional study was conducted at a tertiary care hospital with 83 patients presenting to surgery OPD with neck swelling. Each patient was examined by one trained Junior Resident and a Surgery Consultant with all the four methods and with ultrasonography. Data was analysed by Stata-14, agreement between the two categorical variables was assessed by Kappa. In case of continuous variable agreement was assessed by Intra class correlation and Bland-Altman plot. Results Modified Rose method by the consultant has the highest sensitivity (98%) and diagnostic odds (210) as compared to others but its specificity ranges from 46.7-91.1% to diagnose retro-sternal extension of a goiter. It has 93.98% agreement for identification of nodules. It has a high specificity (Consultant - 100%, Resident - 95.5%) with relatively lower sensitivity (Consultant - 94%, Resident - 86.8%) to diagnose solitary thyroid nodule (STN) but the sensitivity and specificity for diagnosing a multinodular goitre (MNG) was high. However, the highest sensitivity to diagnose STN was highest with Crile’s method, but specificity was low. Lahey’s method was a better clinical method to palpate lymph nodes compared to the other three. Conclusion Examination in modified Rose’s position is a better method of clinical examination of thyroid especially in patients with occult substernal extension. Lahey’s method is a better method to examine cervical lymph nodes.

/pdf/comparison-of-modified-rose-method-of-thyroid-palpation-14wnm78w.pdf

Comparison of Modified Rose Method of Thyroid Palpation Versus Other Methods for the Detection of Retrosternal and Nodular Goitre

/pdf/fitter-insulin-technique-a-psychosocial-commentary-51ks3i32on.pdf

FITTER insulin technique: A psychosocial commentary

Despite of the evident need for psychosocial competence and sensitivity in diabetes care professionals, this field remains sub optimally described in both International Diabetes Federation/American Diabetes Association and National Diabetes Educator Program curricula. This unfortunate omission is formidable challenge for diabetes care and poses an urgent need to amend existing curricula for training of diabetes educators (DEs). Diabetes education programs have exhaustively described the hard skills and also mention the importance of behavioral change, communication skills and cultural competence, yet soft skills of addressing psychosocial concerns have been given a Cinderella treatment. Diabetes educator (DE) has to be professional, personal and like a family member to patient forming a valuable link between treating clinician and the people with diabetes (PwD). Looking at the gap and the future aspects, a universal approach of sensitization which includes both the beneficiary and policy makers has to be adopted. Better description and importance of psychosocial aspects of diabetes have to be included in the curricula for DE training.

https://www.thieme-connect.com/products/ejournals/pdf/10.4103/2321-0656.140900.pdf

Yashdeep Gupta

Papers

Metabolic Syndrome: The drums are beating.

My name is Eklavya: Indian guidelines are necessary.

Comparison of Modified Rose Method of Thyroid Palpation Versus Other Methods for the Detection of Retrosternal and Nodular Goitre

FITTER insulin technique: A psychosocial commentary

Psychosocial management of diabetes: Role of diabetes educator