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The impact of integrating medical assistants and community health workers on diabetes care management in community health centers.
Rodriguez, HP, Friedberg, MW, Vargas-Bustamante, A, Chen, X, Martinez, AE, Roby, DH
BMC health services research. 2018;(1):875
Abstract
OBJECTIVE To compare the impact of implementing team-based diabetes care management involving community health workers (CHWs) vs. medical assistants (MA) in community health centers (CHCs) on diabetes care processes, intermediate outcomes, and patients' experiences of chronic care. DATA SOURCES Clinical and administrative data (n = 6111) and patient surveys (n = 698) pre-intervention and post-intervention. Surveys (n = 285) and key informant interviews (n = 48) of CHC staff assessed barriers and facilitators of implementation. STUDY DESIGN A three-arm cluster-randomized trial of CHC sites integrating MAs (n = 3) or CHWs (n = 3) for diabetes care management compared control CHC sites (n = 10). Difference-in-difference multivariate regression with exact matching of patients estimated intervention effects. PRINCIPAL FINDINGS Patients in the CHW intervention arm had improved annual glycated hemoglobin testing (18.5%, p < 0.001), while patients in the MA intervention arm had improved low-density lipoprotein cholesterol control (8.4%, p < 0.05) and reported better chronic care experiences over time (β=7.5, p < 0.001). Except for chronic care experiences (p < 0.05) for patients in the MA intervention group, difference-in-difference estimates were not statistically significant because control group patients also improved over time. Some diabetes care processes improved significantly more for control group patients than intervention group patients. Key informant interviews revealed that immediate patient care issues sometimes crowded out diabetes care management activities, especially for MAs. CONCLUSIONS Diabetes care improved in CHCs integrating CHWs and MAs onto primary care teams, but the improvements were no different than improvements observed among matched control group patients. Greater improvement using CHW and MA team-based approaches may be possible if practice leaders minimize use of these personnel to cover shortages that often arise in busy primary care practices.
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2.
The prevalence of painful diabetic neuropathy in 300 Moroccan diabetics.
Chahbi, Z, Lahmar, B, Hadri, SE, Abainou, L, Kaddouri, S, Qacif, H, Baizri, H, Zyani, M
The Pan African medical journal. 2018;:158
Abstract
Painful diabetic neuropathy is a frequent complication of diabetes. Its diagnosis is clinical. Our goal is to determine the prevalence of painful diabetic neuropathy in this population. We also analyzed the relationship between this neuropathy and certain parameters, concerning the patient and his diabetes. It is a cross sectional study conducted at the department of endocrinology and internal medicine of Avicenne hospital Marrakech-Morocco, among a cohort of 300 diabetic outpatients. We used the DN4 questionnaire (Douleur Neuropathique en 4 questions), for diagnosis. The results showed a prevalence of 15%. In this study: advanced age, female gender, duration of diabetes greater than 10 years, and the lack of medical follow up were found to be statistically significant risk factors for painful diabetic neuropathy, in addition to some diabetes-related comorbidities such as hypertension, dyslipidemia, sedentary life style and diabetic retinopathy. Painful diabetic neuropathy remains undertreated, in fact 74% of our patients did not receive any specific treatment, knowing that the progress in developing effective and well-tolerated therapies has been disappointing.
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The roles of endothelial nitric oxide synthase gene polymorphisms in diabetes mellitus and its associated vascular complications: a systematic review and meta-analysis.
Dong, J, Ping, Y, Wang, Y, Zhang, Y
Endocrine. 2018;(2):412-422
Abstract
PURPOSE The roles of endothelial nitric oxide synthase (eNOS) gene polymorphisms in diabetes mellitus (DM) were intensively analyzed, but the results of these studies were inconsistent. Therefore, we performed this study to better assess the relationship between eNOS genetic variations and DM. METHODS Eligible studies were searched in PubMed, Medline, Embase, and Web of Science. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess correlations between eNOS polymorphisms and DM. RESULTS A total of 91 studies were finally included in our analyses. Significant associations with the susceptibility to DM were detected for the rs891512, rs1799983, rs2070744, and rs869109213 polymorphisms. As for vascular complications in DM, significant associations with the susceptibility to diabetic nephropathy were detected for the rs1799983 and rs2070744 polymorphisms. In addition, we also found that the rs1799983 polymorphism was significantly associated with the susceptibility to peripheral artery disease, whereas the rs2070744 polymorphism was significantly associated with the susceptibility to coronary artery disease in DM patients. Further subgroup analyses on the basis of type of disease and ethnicity of participants showed similar positive results. CONCLUSIONS In conclusion, our findings indicate that rs891512, rs1799983, rs2070744, and rs869109213 polymorphisms may serve as genetic biomarkers of DM, while rs1799983, rs2070744, and rs869109213 polymorphisms may contribute to the development of vascular complications in DM.
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4.
Nursing care to patients with diabetes based on King's Theory.
Araújo, ESS, Silva, LFD, Moreira, TMM, Almeida, PC, Freitas, MC, Guedes, MVC
Revista brasileira de enfermagem. 2018;(3):1092-1098
Abstract
OBJECTIVE To verify the effectiveness of nursing interventions based on the Imogene King's Theory of Goal Attainment, on improving care for people with diabetes and adherence to treatment. METHOD Quasi-experimental, longitudinal, randomized, simple study in a Primary Health Care Unit, in the city of Fortaleza, Ceará state, Brazil. The sample consisted of 60 people with diabetes, divided into intervention and control groups, whose collection occurred from February to August 2013. RESULTS In the intervention group, a significant adherence of the patients to the goals defined in the study was found. In the control, there was improvement in some aspects of the treatment. CONCLUSION With these results, it was possible to conclude the feasibility of using Theory of Goal Attainment in the positive aspects for adherence to diabetes treatment and improvement of quality of life.
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Drug treatment of hypertension in older patients with diabetes mellitus.
Yandrapalli, S, Pal, S, Nabors, C, Aronow, WS
Expert opinion on pharmacotherapy. 2018;(7):633-642
Abstract
INTRODUCTION Hypertension is more prevalent in the elderly (age>65 years) diabetic population than in the general population and shows an increasing prevalence with advancing age. Both diabetes mellitus (DM) and hypertension are independent risk factors for cardiovascular (CV) related morbidity and mortality. Optimal BP targets were not identified in elderly patients with DM and hypertension. AREAS COVERED In this review article, the authors briefly discuss the pathophysiology of hypertension in elderly diabetics, present evidence with various antihypertensive drug classes supporting the treatment of hypertension to reduce CV events in older diabetics, and then discuss the optimal target BP goals in these patients. EXPERT OPINION Clinicians should have a BP goal of less than 130/80 mm in all elderly patients with hypertension and DM, especially in those with high CV-risk. When medications are required for optimal BP control in addition to lifestyle measures, either thiazide diuretics, angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, or calcium channel blockers should be considered as initial therapy. Combinations of medications are usually required in these patients because BP control is more difficult to achieve in diabetics than those without DM.
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Theoretical overview of clinical and pharmacological aspects of the use of etelcalcetide in diabetic patients undergoing hemodialysis.
Ye, J, Deng, G, Gao, F
Drug design, development and therapy. 2018;:901-909
Abstract
Etelcalcetide is the first intravenous calcimimetic agent authorized for the treatment of secondary hyperparathyroidism (sHPT) in patients undergoing hemodialysis in Europe, the US, and Japan. The relationship between sHPT and diabetes resides on complex, bidirectional effects and largely unknown homeostatic mechanisms. Although 30% or more patients with end-stage renal disease are diabetics and about the same percentage of those patients suffer from sHPT associated with hemodialysis, no data on the specificities of the use of etelcalcetide in such patients are available yet. Regarding pharmacokinetic interactions, etelcalcetide may compete with oral hypoglycemics recommended for use in patients undergoing hemodialysis and insulins detemir and degludec, causing unexpected hypocalcemia or hypoglycemia. More importantly, hypocalcemia, a common side effect of etelcalcetide, may cause decompensation of preexisting cardiac insufficiency in diabetic patients or worsen dialysis-related hypotension and lead to hypotension-related cardiac events, such as myocardial ischemia. In diabetic patients, hypocalcemia may lead to dangerous ventricular arrhythmias, as both insulin-related hypoglycemia and hemodialysis prolong QT interval. Patients with diabetes, therefore, should be strictly monitored for hypocalcemia and associated effects. Due to an altered parathormone activity in this patient group, plasma calcium should be the preferred indicator of etelcalcetide effects. Until more clinical experience with etelcalcetide is available, the clinicians should be cautious when using this calcimimetic in patients with diabetes.
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Duration of Dual Antiplatelet Therapy Following Drug-Eluting Stent Implantation in Diabetic and Non-Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Sharma, A, Garg, A, Elmariah, S, Drachman, D, Obiagwu, C, Vallakati, A, Sharma, SK, Lavie, CJ, Mukherjee, D, Waksman, R, et al
Progress in cardiovascular diseases. 2018;(4-5):500-507
Abstract
BACKGROUND Diabetic patients account for an increasing number of patients undergoing percutaneous coronary intervention (PCI). However, diabetes mellitus (DM) is associated with increased residual platelet activity during dual antiplatelet treatment (DAPT) and DM patients have worse clinical outcomes after PCI as compared to non-DM. OBJECTIVE To evaluate efficacy and safety of short duration DAPT (S-DAPT) and long duration DAPT (L-DAPT) after drug eluting stent (DES) implantation in DM and non-DM patients. METHODS We searched Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials (RCTs) assessing the effect of S-DAPT versus L-DAPT after DES implantation in DM and non-DM patients. Efficacy endpoints were all-cause mortality, cardiac mortality, myocardial infarction (MI), stent thrombosis (ST), target vessel revascularization (TVR), and composite end point of net adverse clinical events (NACE) (all-cause mortality, cardiac mortality, MI, ST, TVR, stroke, major bleeding). Safety endpoints were major bleeding and stroke. Event rates were compared using a forest plot of relative risk using a random effects model. RESULTS We included eight RCTs that randomized 28,318 patients to S-DAPT versus L-DAPT (8234 DM and 20,084 non-DM). S-DAPT was associated with an increased rate of ST in non-DM patients [3.67 (2.04, 6.59)]. There was no significant difference in the rate of all-cause mortality, cardiac mortality, ST, MI, TVR, major bleeding, stroke and NACE with S-DAPT and L-DAPT in DM patients [1.19 (0.72-1.95); 1.25 (0.69, 2.25); 1.52 (0.70, 3.29); 1.33 (0.88, 2.01); 1.39 (0.89, 2.17); 0.92 (0.19, 4.42); 0.98 (0.29, 3.28); and 0.94 (0.57, 1.54) respectively]. Further, there was no significant difference in the rate of all-cause mortality, cardiac mortality, MI, TVR, major bleeding, stroke and NACE with S-DAPT and L-DAPT in non-DM patients [0.93 (0.58, 1.48); 0.75 (0.42, 1.35); 1.52 (0.81, 2.83); 0.99 (0.71, 1.39); 0.72 (0.28, 1.84); 1.01 (0.40, 2.56); and 1.01 (0.77, 1.32) respectively]. CONCLUSION Compared to L-DAPT, S-DAPT was associated with significant increase in rate of ST in non-DM patients. Duration of DAPT had no significant impact on rates of all-cause mortality, cardiac mortality, MI, ST and TVR among DM patients.
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8.
Modalities for assessing the nutritional status in patients with diabetes and cancer.
Clemente, G, Gallo, M, Giorgini, M, ,
Diabetes research and clinical practice. 2018;:162-172
Abstract
Epidemiological data have shown that an increased body mass index (BMI) is associated with a higher risk of various cancers, especially in obese diabetic patients. However, oncologic patients often present nutritional alterations that can worsen their prognosis. The aim of this review is to propose the use of cheaper and easy to use tools to assess the nutritional status of patients with cancer with altered glucose metabolism. Based on a literature review, we propose anthropometric measures to classify the degree of malnutrition. Moreover, the Karnofsky Performance Status (KPS) and the Eastern Cooperative Oncology Group's performance index (ECOG) are useful to assess the functional status of the body; the achievement of nutritional needs can be analysed with the PG-SGA questionnaire, while the quality of life can be investigated using the DTSQ, SF36, EQ-5D questionnaires and the Edmonton Symptom Assessment System. Pre-albumin dosage and lymphocyte count are proposed as nutritional parameters. The degree of hydration can be evaluated through the Bio-Impedance Test (BIA), and energy intake through the dairy food diary, which considers the type of nutrition and the consistency of the meals. It is possible to use a score for each tool used, which is useful to plan an adequate nutritional intervention.
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[Diabetology and solid organ transplantation].
Wagner, L, Wittmann, I, Piros, L, P Szabó, R, Szakály, P
Orvosi hetilap. 2018;(46):1930-1939
Abstract
Diabetes increases the risk of different kidney diseases. The most important is diabetic nephropathy, however, ischemic kidney disease, chronic pyleonephritis and papilla necrosis may also develop. The prognosis of diabetic nephropathy has improved recently, however, it is still the primary cause of dialysis and transplantation. Cardiovascular diseases predict mostly mortality in diabetic patients, however, cerebrovascular insults and peripheral obstructive arterial diseases necessitating lower limb amputations are also important. Diabetic retinopathy is almost always present with diabetic nephropathy. Diabetic neuropathy may also develop, furthermore vascular complications often combine. All these urge complex workup, follow-up and early treatment. If transplantation is indicated, preemptive operation should be preferred, and living donation shows the best outcomes. Different forms of carbohydrate disorder may occur after transplantation: new-onset diabetes or diabetes known before transplantation may progress. Renal transplantation with pancreas transplantation may be indicated in type 1 diabetes with end-stage diabetic nephropathy, most often simultaneously. This may result in normoglycemia and insulin-independence and the progression of other complications may also halt. Transplant associated hyperglycemia occurs in most of the patients early, however, it is often transitory. Despite stabilization of the patient and of the immunosuppressive therapy, about one third of the patients may develop posttransplant diabetes. Insulin secretion disorder is the primary cause, but insulin resistance is also needed. Insulin administration may help, however, other antidiabetics can also be useful. Carbohydrate metabolism should be checked in both cadaveric and living donors. The authors make an attempt to summarize the above conditions with Hungarian relevance as well. Orv Hetil. 2018; 159(46): 1930-1939.
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10.
Diabetes mellitus and the risk of abdominal aortic aneurysm: A systematic review and meta-analysis of prospective studies.
Aune, D, Schlesinger, S, Norat, T, Riboli, E
Journal of diabetes and its complications. 2018;(12):1169-1174
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Abstract
BACKGROUND Diabetes mellitus has been associated with reduced risk of abdominal aortic aneurysm in a number of epidemiological studies, however, until recently little data from prospective studies have been available. We therefore conducted a systematic review and meta-analysis of prospective studies to quantify the association. MATERIAL AND METHODS Two investigators searched the PubMed and Embase databases for studies of diabetes and abdominal aortic aneurysm up to May 8th 2018. Prospective studies were included if they reported adjusted relative risk (RR) estimates and 95% confidence intervals (95% CIs) of abdominal aortic aneurysm associated with a diabetes diagnosis. Summary relative risks were estimated by use of a random effects model. RESULTS We identified 16 prospective studies with 16,572 cases among 4,563,415 participants that could be included in the meta-analysis. The summary RR for individuals with diabetes compared to individuals without diabetes was 0.58 (95% CI: 0.51-0.66, I2 = 40.4%, pheterogeneity = 0.06). The results persisted when stratified by sex, duration of follow-up, and in most of the other subgroup analyses. There was no evidence of publication bias with Egger's test, p = 0.64 or by inspection of the funnel plots. CONCLUSIONS These results suggest that individuals with diabetes mellitus are at a reduced risk of abdominal aortic aneurysm, however, whether pharmacological agents for diabetes mellitus explain this observation needs to be clarified in future studies.