New global recommendations: a multidisciplinary approach to improving outcomes in diabetes

Development of explicit definitions of potentially inappropriate prescriptions for antidiabetic drugs in patients with type 2 diabetes: A multidisciplinary qualitative study

PURPOSE

The management of type 2 diabetes mellitus patients has changed over the past decade, and a large number of antidiabetic drug treatment options are now available. This complexity poses challenges for healthcare professionals and may result in potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus which can be limited using screening tools. The effectiveness of explicit tools such as lists of potentially inappropriate prescriptions has been widely demonstrated. The aim was to set up nominal groups of healthcare professionals from several disciplines and develop a list of explicit definition of potentially inappropriate prescriptions of antidiabetic drugs.

METHODS

In a qualitative, nominal-groups approach, 30 diabetologists, general practitioners, and pharmacists in France developed explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus. A nominal group technique is a structured method that encourages all the participants to contribute and makes it easier to reach an agreement quickly. Each meeting lasted for two hours.

RESULTS

The three nominal groups comprised 14 pharmacists, 10 diabetologists, and 6 general practitioners and generated 89 explicit definitions. These definitions were subsequently merged and validated by the steering committee and nominal group participants, resulting in 38 validated explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs. The definitions encompassed four contexts: (i) the temporary discontinuation of a medication during acute illness (n = 9; 24%), (ii) dose level adjustments (n = 23; 60%), (iii) inappropriate treatment initiation (n = 3; 8%), and (iv) the need for further monitoring in the management of type 2 diabetes mellitus (n = 3; 8%).

CONCLUSION

The results of our qualitative study show that it is possible to develop a specific list of explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus by gathering the opinions of healthcare professionals caring for these patients. This list of 38 explicit definitions necessitates additional confirmation by expert consensus before use in clinical practice.

Is 'Cardiopulmonary' the New 'Cardiometabolic'? Making a Case for Systems Change in COPD

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) have a syndemic relationship with shared risk factors and complex interplay between genetic, environmental, socioeconomic, and pathophysiological mechanisms. CVD is among the most common comorbidities in patients with COPD and vice versa. Patients with COPD, irrespective of their disease severity, are at increased risk of CVD morbidity and mortality, driven in part by COPD exacerbations. Despite these known interrelationships, CVD is underestimated and undertreated in patients with COPD. Similarly, COPD is an independent risk-enhancing factor for adverse cardiovascular (CV) events, yet it is not incorporated into current CV risk assessment tools, leading to under-recognition and undertreatment. There is a pressing need for systems change in COPD management to move beyond symptom control towards a comprehensive cardiopulmonary disease paradigm with proactive prevention of exacerbations and adverse cardiopulmonary outcomes and mortality. However, there is a dearth of evidence defining optimal cardiopulmonary care pathways. Fortunately, there is a precedent to support systems-level change in the field of diabetes, which evolved from glycemic control to comprehensive multi-organ risk assessment and management. Key elements included integrated multidisciplinary care, intensive risk factor management, coordination between primary and specialist care, care pathways and protocols, education and self management, and disease-modifying therapies. This commentary article draws parallels between the cardiometabolic and cardiopulmonary paradigms and makes a case for systems change towards multidisciplinary, integrated cardiopulmonary care, using the evolution in diabetes care as a potential framework.

Assessing perceptions of nursing knowledge, attitudes, and practices in diabetes management within Chinese healthcare settings

Background

Effective management of diabetes mellitus (DM) involves comprehensive knowledge, attitudes, and practices (KAP) by nurses, which is essential for optimal patient care and aiding patients in their self-management of the condition.

Method

This survey evaluates nurses' self-assessed knowledge, attitudes, and practices (KAP) related to diabetes management, focusing on their perceptions of personnel expertise and care approaches. Using a stratified sampling method, the survey was disseminated across various online platforms from January 2023 to February 2024 within China, including WeChat and Sina Weibo. We employed binary logistic regression and Chi-square tests to explore the statistical correlates of KAP related to DM.

Results

A total of 4,011 nurses participated, revealing significant perceived knowledge deficiencies in specialized DM management areas, with only 34% (n = 1,360) proficient in current pharmacological treatments. Attitudinal assessments showed that 54% (n = 2,155) recognized the importance of cultural competence in dietary counseling. Practices were strong in routine glucose monitoring (96%, n = 3,851) but weaker in psychological support (68%, n = 2,736). Regression analysis indicated significant effects of experience on KAP, where nurses with 1-5 years of experience were more likely to show better knowledge (OR = 1.09; p = 0.08), and those with advanced degrees demonstrated higher competence (OR = 1.52; p = 0.028). Marital status influenced attitudes, with single nurses more likely to exhibit positive attitudes (OR = 0.49; p < 0.001), and work environment impacted knowledge, with hospital-based nurses more knowledgeable (OR = 1.15; p = 0.14). Additionally, gender differences emerged, with male nurses showing greater knowledge (OR = 1.65; p = 0.03) and better practices in diabetes care (OR = 1.47; p = 0.04).

Conclusion

The study underscores the critical need for targeted educational programs and policy interventions to enhance nursing competencies in DM management. While the study provides valuable insights into nurses' perceptions of their competencies, future research should incorporate objective knowledge assessments to ensure a comprehensive understanding of their actual capabilities. Interestingly, the data also suggests a substantial opportunity to leverage technology and inter-professional collaboration to further enhance DM management efficacy among nurses, fostering an integrated care approach.

Team-Based Diabetes Care in Ontario and Hong Kong: a Comparative Review

PURPOSE OF REVIEW

There are gaps in implementing and accessing team-based diabetes care. We reviewed and compared how team-based diabetes care was implemented in the primary care contexts of Ontario and Hong Kong.

RECENT FINDINGS

Ontario's Diabetes Education Programs (DEPs) were scaled-up incrementally. Hong Kong's Multidisciplinary Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) evolved from a research-driven quality improvement program. Each jurisdiction had a mixture of non-team and team-based primary care with variable accessibility. Referral procedures, follow-up processes, and financing models varied. DEPs used a flexible approach, while the RAMP-DM used structured assessment for quality assurance. Each approach depended on adequate infrastructure, processes, and staff. Diabetes care is most accessible and functional when integrated team-based services are automatically initiated upon diabetes diagnosis within a strong primary care system, ideally linked to a register with supports including specialist care. Structured assessment and risk stratification are the basis of a well-studied, evidence-based approach for achieving the standards of team-based diabetes care, although flexibility in care delivery may be needed to meet the unique needs of some individuals. Policymakers and funders should ensure investment in skilled health professionals, infrastructure, and processes to improve care quality.

The multidisciplinary team in diagnosing and treatment of patients with diabetes and comorbidities: A scoping review

Background

Multidisciplinary Teams (MDTs) has been suggested as an intervention to overcome some of the complexities experienced by people with diabetes and comorbidities in terms of diagnosis and treatment. However, evidence concerning MDTs within the diabetes field remains sparse.

Objective

This review aims to identify and map available evidence on key characteristics of MDTs in the context of diagnosis and treatment in people with diabetes and comorbidities.

Methods

This review followed the PRISMA-ScR guidelines. Databases PubMed, EMBASE, and CINAHL were systematically searched for studies assessing any type of MDT within the context of diagnosis and treatment in adult people (≥ 18 years) with diabetes and comorbidities/complications. Data extraction included details on study characteristics, MDT interventions, digital health solutions, and key findings.

Results

Overall, 19 studies were included. Generally, the MDTs were characterized by high heterogeneity. Four overall components characterized the MDTs: Both medical specialists and healthcare professionals (HCPs) of different team sizes were represented; interventions spanned elements of medication, assessment, nutrition, education, self-monitoring, and treatment adjustment; digital health solutions were integrated in 58% of the studies; MDTs were carried out in both primary and secondary healthcare settings with varying frequencies. Generally, the effectiveness of the MDTs was positive across different outcomes.

Conclusions

MDTs are characterized by high diversity in their outline yet seem to be effective and cost-effective in the context of diagnosis and treatment of people with diabetes and comorbidities. Future research should investigate the cross-sectorial collaboration to reduce care fragmentation and enhance care coordination.

Patient-perceived and practitioner-perceived barriers to accessing foot care services for people with diabetes mellitus: a systematic literature review

BACKGROUND

Foot-related complications are common in people with diabetes mellitus, however foot care services are underutilized by this population. This research aimed to systematically review the literature to identify patient and practitioner-perceived barriers to accessing foot care services for people with diabetes.

METHODS

PRISMA guidelines were used to inform the data collection and extraction methods. CINAHL, MEDLINE, and Scopus databases were searched in March 2022 to identify original research articles that reported on barriers to accessing diabetes foot care services from the patient and/or practitioner perspective. Both quantitative and qualitative studies were included. The methodological quality of included studies was assessed using the Critical Appraisal Skills Program (CASP) tool for qualitative/mixed methods studies or the National Heart, Lung & Blood Institute (NHLBI) tool for quantitative studies. Following data extraction, content analysis was used to identify reported barriers. Themes and subthemes were presented separately for patient-perspectives and practitioner-perspectives. A narrative summary was used to synthesize the findings from the included studies.

RESULTS

A total of 20 studies were included. The majority of CASP and NHLBI criteria were met by most studies, indicating good overall methodological quality. Three predominant themes emerged from the patient perspective that represented barriers to accessing foot care services: lack of understanding, socioeconomic factors, and lack of service availability. Four themes emerged from the practitioner perspective: poor interprofessional communication, lack of resources, lack of practitioner knowledge, and perceived patient factors.

CONCLUSIONS

This study has identified a number of barriers to accessing foot care services from both the patient and practitioner perspectives. Although patients focused predominantly on patient-level factors, while practitioners focused on barriers related to the health care system, there was some overlap between them. This emphasizes the importance of recognising both perspectives for the future integration of policy changes and access facilitators that may help to overcome these barriers.

Association of clinically significant weight loss with number of patient visits and months of attendance at an Australian multidisciplinary weight management clinic

Despite the obesity epidemic, there are relatively few multidisciplinary obesity services in Australia, and only limited data on the effectiveness of these services. The aim of this study was to evaluate the effectiveness of a university hospital-based weight management clinic-the 'Healthy Weight Clinic' in supporting patients to achieve clinically significant weight loss (≥5% reduction in body weight), weight maintenance, and changes in body composition. A retrospective review was conducted to determine weight and associated health outcomes in patients who attended an initial consultation in the first 2 years of the clinic-between March 2017 and March 2019. Follow up was at least 1 year for all patients. Patients who underwent bariatric surgery were excluded. Of 213 total patients, 172 patients attended more than one follow-up consultation for lifestyle modification. Mean weight change and percentage total weight change at last follow-up was -6.2 kg (SD 7.4) and - 6.0% (SD 6.9), respectively. For every additional clinic follow-up, there was 21.4% increased odds of achieving clinically significant weight loss, and for every additional month of follow-up, there was 10.1% increased odds of achieving clinically significant weight loss. Twenty percent of patients (34/172) maintained ≥5% of initial body weight loss for at least 1 year. Body composition measurements were also favourable, with significant changes in percentage skeletal muscle mass of +0.8% (SD 1.5) and in percentage fat mass by -1.4% (SD 3.2). Regular support in a structured holistic multidisciplinary obesity service enables patients to achieve clinically meaningful weight loss and improved skeletal muscle mass to body fat ratio, and maintain this loss for at least 1 year. Improved weight loss was associated with more patient visits and longer duration of attendance at the clinic.

Patient and family perceptions of interprofessional collaborative teamwork: An integrative review

AIMS

To understand the patient and family perceptions of teamwork by synthesising existing evidence using the Interprofessional Education Collaborative Core Competencies for Interprofessional Collaborative Practice as a guiding framework.

BACKGROUND

Advances in healthcare have resulted in more people living longer with health conditions, and patients and families have become the primary caregivers. The role of the interprofessional collaborative team supports a paradigm shift to a care model with the patient and family at the centre of healthcare decisions. However, patient and family views of interprofessional collaborative team care have rarely been studied.

METHODS

The authors applied Whittmore and Knafl's methodology to conduct an integrative review of the literature. Databases searched included Cumulative Index to Nursing and Allied Health Literature, PubMed and PsycINFO along with reference searches. The studies included were those related to patient and family perceptions of teamwork published from 2000 to 2020. The IPEC Core Competencies for Interprofessional Collaborative Practice served as the guiding framework for analysis. A PRISMA flow chart documented the search, inclusion and exclusion criteria for the review.

RESULTS

Seventeen articles met the inclusion criteria. The findings identified differing perspectives by patients of the impact of the interprofessional collaborative team in their care which suggests that interventions to increase knowledge about interprofessional collaborative team care from the patient and family perspective may be beneficial.

CONCLUSIONS

There is limited research on understanding IPC teams from the patient and family viewpoint. This review reveals incongruencies in patient and provider perspectives of IPC teams and suggests the need for additional research about patient and family perspectives of teamwork. To fully implement the IPC team vision, perceptions of teamwork must be fully understood.

Healthcare Professionals' Views of Factors Influencing Diabetes Self-Management and the Utility of a mHealth Application and Its Features to Support Self-Care

INTRODUCTION

The perspectives of healthcare professionals (HCPs) are pivotal to co-development of self-management strategies for patients with diabetes. However, literature has been largely limited to perspectives of patients within the context of a Western healthcare setting. This study aims to explore factors influencing diabetes self-management in adult patients with diabetes from the perspectives of HCPs and their views of the value of mHealth application for diabetes self-management.

MATERIALS AND METHODS

We conducted focus group discussions (FGD) with purposively selected HCPs in Singapore. All FGDs were audio-recorded and transcribed verbatim. Thematic analysis was conducted using NVivo 12.

RESULTS

A total of 56 HCPs participated in the study. Barriers to self-management included limited patient commitment to lifestyle changes, suboptimal adherence to medication and treatment, patient resistance to insulin initiation and insufficient rapport between patients and HCPs. Patients' perceived susceptibility to complications, social support from family and community, multidisciplinary team care and patient's understanding of the benefits of self-care were viewed as facilitating self-management. HCPs saw mHealth apps as a vital opportunity to engage patients in the self-management of conditions and empower them to foster behavior changes. Yet, there were concerns regarding patient's limited digital literacy, lack of integration into routine electronic system and reluctance.

DISCUSSION

We identified a set of factors influencing self-management in adult patients with diabetes and useful app features that can empower patients to manage their conditions. Findings will inform the development of a mHealth application, and its features designed to improve self-care.

Cost-effectiveness of a self-management and comprehensive training intervention in patients with type 2 diabetes up to 5 years of diagnosis in a specialized hospital in Mexico City

INTRODUCTION

To assess the cost-effectiveness of a multidisciplinary and comprehensive innovative diabetes care program (CAIPaDi) versus usual treatment in public health institutions.

RESEARCH DESIGN AND METHODS

Using a cost-effectiveness analysis, we compared the CAIPaDi program versus usual treatment given in Mexican public health institutions. The analysis was based on the IQVIA Core Diabetes Model, a validated simulation model used to estimate long-term clinical outcomes. Data were prospectively obtained from the CAIPaDi program and from public databases and published papers. Health outcomes were expressed in terms of life-years gained and quality-adjusted life years (QALYs). Health and economic outcomes were estimated from a public perspective and discounted at 5% per year over a 20-year horizon. Costs are reported in US dollars (US$) of 2019. A probabilistic sensitivity analysis was performed using life-years gained and QALYs.

RESULTS

The CAIPaDi costs on average US$559 (95% CI: -$879 to -$239) less than the usual treatment (95% CI: -$879 to -$239) and produced a difference in mean life-years gained (0.48, 95% CI: 0.45 to 0.52) and mean QALYs (1.43, 95% CI: 1.40 to 1.46). The cost-effectiveness ratio resulted in a saving per life-year gained of -US$1155 (95% CI: -$1962 to -$460). Mean differences in QALYs resulted in a saving per QALY of -US$735 (95% CI: -$1193 to -$305). Probabilistic sensitivity analysis proved the results are robust on both life-years gained and QALYs.

CONCLUSIONS

CAIPaDi has a better cost-effectiveness ratio than the usual therapy in Mexican public health institutions.

Implementation and evaluation of a specialized diabetes clinic in Guinea-Bissau: lessons learnt from the field

Introduction

diabetes care in Guinea-Bissau (GB) is characterized by a lack of properly trained healthcare professionals (HCPs) and guidelines for diagnosis, treatment and follow up of patients. To address these issues, this project was launched with the objective to train HCPs in the management of diabetic patients and establish a specialized diabetes clinic in the Hospital Nacional Simão Mendes, a public tertiary care hospital in Bissau, capital of GB. This project is led by the Geneva University Hospitals (HUG) in collaboration with the Swiss Association for the Aid to Diabetic People in Guinea-Bissau, with the support of the International Solidairty Office (SSI) of the State of Geneva, and AIDA (Ayuda, Intercambio y Desarrollo).

Methods

specialists from the HUG in collaboration with local experts in GB developed and delivered a culturally and contextually adapted training course pertaining to diabetes care to HCPs in this hospital. Pre and post training tests were conducted to assess differences in knowledge and practices. Following the training program, a diabetes clinic was set up and an audit was conducted to assess its performance.

Results

a total of 24 HCP attended the training program and exhibited statistically significant improvements in their knowledge pertaining to diabetes care (mean difference between pre and post-test = 14.53, SD 11.60, t=-4.8, p < 0.001). The diabetes clinic was established and provided consultations 2 days per week. A total of 63 patients consulted at this clinic, of which 49 had type two diabetes treated with oral antidiabetic drugs and 14 were type 1 diabetics treated with insulin. Patients had blood glucose measurements and received therapeutic, dietary and physical activity counselling. Several barriers leading to occasional interruptions of service were encountered, including a political instability in the country and strikes of healthcare staff demanding better wages and working conditions.

Conclusion:

this study delineates the feasibility of setting up a diabetes consultation clinic in GB despite important barriers. To ensure successful running of such consultation clinics, continued buy-in and support from stakeholders should be ensured. Diabetes training should be incorporated in pre-and post-graduate training curriculums of all HCP to help shape a better workforce.

Development and Implementation of a Decision Support System to Improve Control of Hypertension and Diabetes in a Resource-Constrained Area in Brazil: Mixed Methods Study

BACKGROUND

The low levels of control of hypertension and diabetes mellitus are a challenge that requires innovative strategies to surpass barriers of low sources, distance, and quality of health care.

OBJECTIVE

The aim of this study is to develop a clinical decision support system (CDSS) for diabetes and hypertension management in primary care, to implement it in a resource-constrained region, and to evaluate its usability and health care practitioner satisfaction.

METHODS

This mixed methods study is a substudy of HealthRise Brazil Project, a multinational study designed to implement pilot programs to improve screening, diagnosis, management, and control of hypertension and diabetes among underserved communities. Following the identification of gaps in usual care, a team of clinicians established the software functional requirements. Recommendations from evidence-based guidelines were reviewed and organized into a decision algorithm, which bases the CDSS reminders and suggestions. Following pretesting and expert panel assessment, pilot testing was conducted in a quasi-experimental study, which included 34 primary care units of 10 municipalities in a resource-constrained area in Brazil. A Likert-scale questionnaire evaluating perceived feasibility, usability, and utility of the application and professionals' satisfaction was applied after 6 months. In the end-line assessment, 2 focus groups with primary care physicians and nurses were performed.

RESULTS

A total of 159 reminders and suggestions were created and implemented for the CDSS. At the 6-month assessment, there were 1939 patients registered in the application database and 2160 consultations were performed by primary care teams. Of the 96 health care professionals who were invited for the usability assessment, 26% (25/96) were physicians, 46% (44/96) were nurses, and 28% (27/96) were other health professionals. The questionnaire included 24 items on impressions of feasibility, usability, utility, and satisfaction, and presented global Cronbach α of .93. As for feasibility, all professionals agreed (median scores of 4 or 5) that the application could be used in primary care settings and it could be easily incorporated in work routines, but physicians claimed that the application might have caused significant delays in daily routines. As for usability, overall evaluation was good and it was claimed that the application was easy to understand and use. All professionals agreed that the application was useful (score 4 or 5) to promote prevention, assist treatment, and might improve patient care, and they were overall satisfied with the application (median scores between 4 and 5). In the end-line assessment, there were 4211 patients (94.82% [3993/4211] with hypertension and 24.41% [1028/4211] with diabetes) registered in the application's database and 7960 consultations were performed by primary health care teams. The 17 participants of the focus groups were consistent to affirm they were very satisfied with the CDSS.

CONCLUSIONS

The CDSS was applicable in the context of primary health care settings in low-income regions, with good user satisfaction and potential to improve adherence to evidence-based practices.

Perceived Barriers, Benefits, Facilitators, and Attitudes of Health Professionals Towards Multidisciplinary Team Care in Type 2 Diabetes Management: A Systematic Review

BACKGROUND

The need for a multidisciplinary team approach to provide physical exercise, diet, behavioral change, and insulin therapy in type 2 diabetes mellitus (T2DM) treatment has long been recognized. However, often patients with T2DM do not have access to a multidisciplinary team.

INTRODUCTION

In developing countries, most patients with T2DM receive their diabetes care in the office of an internist or family practice physician or in a primary level health center with a general practitioner. Knowledge of healthcare professionals regarding the perceived barriers, attitudes, facilitators, and benefits of a multidisciplinary team approach in T2DM treatment can help facilitate the implementation of multidisciplinary care in T2DM.

METHODS

A systematic search strategy was performed in six databases (PubMed, Web of Science, CINAHL, EMBASE, MEDLINE, and Cochrane) using different keyword combinations to identify studies describing the healthcare professionals' views of multidisciplinary team care in T2DM. A textual narrative synthesis was used to analyze data. The Critical Appraisals Skills Programme (CASP) tool for qualitative studies was used to assess the risk of bias and transferability.

RESULTS

The views of health professionals about multidisciplinary team care in T2DM were categorized into six major factors, namely working collaboratively to foster supportive relationships; strong committed organizational and team leadership; diversity in expertise, with team members tailored to local circumstances; shared goals and approaches to ensure consistency of message; clear and open communication with the team and with patients; and the patient at the center of decision- making.

CONCLUSION

There is a huge gap in shared roles among health professionals in T2DM therapy. Hence, there is a need for allied health professionals such as physiotherapists, dieticians, and psychologists with expertise in diabetes to explore primary healthcare, barriers and facilitators to the successful integration of multidisciplinary team, seamlessly distributedinto three hierarchal levels, namely health management, health professionals, and diabetic patients.

Influence of the Model of Care on the Outcomes of Diabetes Self-Management Education Program: A Scoping Review

BACKGROUND

Type 2 diabetes mellitus (T2DM) accounts for approximately 95% of all diabetes cases, making the disease a global public health concern. The increasing prevalence of T2DM has highlighted the importance of evidence-based guidelines for effective prevention, management, and treatment. Diabetes self-management education (DSME) can produce positive effects on patient behaviors and health status. Study objective. We synthesized findings from the existing studies to find out whether or not the impact of DSME on patient health behaviors and outcomes differ by the different models of diabetes care. That is, we determined whether there are differences in DSME outcomes when patient's care provider is a general practitioner, a specialist, a nurse, or a combination of these health professionals.

METHODS

Searches were made of six electronic databases to identify relevant English language publications on DSME from 2000 through 2019. Titles and abstracts of the search results were screened to select eligible papers for full-text screening. All eligible papers were retrieved, and full-text screening was done by three independent reviewers to select studies for inclusion in the final analysis. Twenty-one studies were included in the final analysis. The main outcome measures assessed were glycated hemoglobin (HbA1c), body mass index (BMI), diet, and physical activity.

RESULTS

The majority of the patients with diabetes were seen by primary care physicians. In general, the studies reported significant improvements in patient health behaviors and outcomes. Some differences in outcomes between the different models of care were observed.

CONCLUSION

Our findings suggest that the effects of DSME on patients' health behaviors and outcomes could differ by the different models of diabetes care. However, considering the limited sample of publications reviewed, and because none of the reviewed studies directly measured the impact of the DSME program on patient behaviors and outcomes, significant conclusions could not be reached.

Cost-effectiveness analysis of a multidisciplinary health-care model for patients with type-2 diabetes implemented in the public sector in Mexico: A quasi-experimental, retrospective evaluation

OBJECTIVE

In 2007, the Ministry of Health (MoH) in Mexico implemented a multidisciplinary health-care model (MHC) for patients with type-2 diabetes (T2D), which has proven more effective in controlling this condition than the conventional health-care model (CHC).

RESEARCH DESIGN AND METHODS

We compared the cost-effectiveness of the MHC vs. the CHC for patients with T2D using a quasi-experimental, retrospective design. Epidemiologic and cost data were obtained from a randomly selected sample of health-care units, using medical records as well as patient- and facility-level data. We modelled the cost-effectiveness of the MHC at one, 10 and 20 years using a simulation model.

RESULTS

The average cumulative costs per patient at 20 years were US$4,225 for the MHC and US$4,399 for the CHC. With a willingness to pay one gross domestic product (GDP) per capita per quality-adjusted life year (QALY) (US$8,910), the incremental net benefits per patient were US$1,450 and US$3,737 at 10 and 20 years, respectively. The MHC was cost-effective from the third year onward; however, increasing coverage to 500 patients per year rendered it cost-effective at year one.

CONCLUSIONS

The MHC is cost-effective at 10 and 20 years. Cost-effectiveness can be achieved in the short term by increasing MHC coverage.

One-pot synthesis of the organomodified layered double hydroxides - glibenclamide biocompatible nanoparticles

In this work, synthesis of sodium dodecyl sulfate (SDS) organomodified LDH Zn₂Al carrying glibenclamide (GLIB) was performed in one step and in one-pot to obtain nanoparticles (NP). XRD data showed GLIB adsolubilization (d = 14.03 Å) and NP coating with Eudragit L100®. In addition, thermal and XRD data showed exfoliated/intercalated nanocomposite for NP S5 (LDH associated with SDS and Eudragit L100®). LDH organophilization and GLIB intercalation reduced surface area (SBET 23.58 m²/g) and NP size (469 nm). In addition, the change in zeta potential (-35.5 ζ) relative to pristine LDH (SBET 41.34 m²/g, 688.8 nm and +14 ζ) indicated that LDH functionalization seems an appropriate approach to produce NP with greater colloidal stability and enhanced functionality. The zinc release data from the LDH matrix (2.96 % ±0.002 ppm) showed the effectiveness of the coating in acid medium (pH 1.2) and the release data from GLIB showed the kinetics of release of zero order with release in simulated intestinal medium (pH 7.4) of 88 % and 73 % (24 h) for uncoated and coated NP, respectively. All NP were considered biocompatible in the WST-1 assay on BALB 3T3 fibroblast strains making these NP promising therapeutically.

Satisfaction with quality of healthcare at primary healthcare settings: Perspectives of patients with type 2 diabetes mellitus

Background

Measuring client satisfaction is part of the quality assurance process and has become an integral part of healthcare management strategies globally. It is essential for improvement of amenities in healthcare facilities.

Objectives

The aim of this study was to assess patients with type 2 diabetes' satisfaction with healthcare services at primary healthcare settings in the Cape Metropolitan district, Western Cape, South Africa.

Methods

This cross-sectional study used proportionate stratified random sampling. The Patient Survey for Quality of Care scale was used to assess patients with type 2 diabetes' satisfaction with quality of care received. Descriptive and inferential statistics were employed in the analysis of the quantitative data. The open-ended question was analysed qualitatively.

Results

The majority of patients were satisfied with the overall quality of care. Dissatisfaction was reported for waiting time to get appointments at the clinic, to see a healthcare professional on the same day and clarity of instructions for managing their diabetes.

Conclusion

Employing more staff in the multidisciplinary team and improving health information by developing staff through continuous education could foster more positive experiences and provide care that contributes to the well-being of patients.

Clinical implications

Addressing patients' views regarding quality of healthcare services could assist in overall improvement of healthcare provision through the rectification of the system weaknesses. Satisfaction with quality of care could positively affect adherence to treatment protocols that could lead to better quality of life of patients with type 2 diabetes.

Survey evaluation of in-hospital diabetes seminars provided by medical professionals, for medical professionals

Purpose: Diabetes is a multifactorial disease, and interprofessional teamwork is essential for its treatment. For successful interprofessional teamwork, individual medical professionals need to have certain skills, experience, and mutual understanding of the role of different professions. However, there are few opportunities to educate medical professionals to meet these demands. To resolve this problem, educational seminars about diabetes were conducted by and for medical professionals, and their effects were assessed using a questionnaire survey. Participants and methods: Medical professionals, including a dietician, a physiotherapist, a pharmacist, a clinical laboratory technician, and a doctor, provided 10 lectures, approximately 50 mins each, for medical professionals about their specialized skills in diabetes care. Nurses who were certified diabetes educators in Japan planned and organized the seminars. In every seminar, participants were asked to complete a questionnaire regarding their profession, motivation to attend the seminar, general comments about the seminar, expectations regarding future seminars, and effects of the seminar on their daily work or attitude toward patients. Results: Among the 367 participants, 332 completed the questionnaire (respondents). The results revealed that by attending the seminars, some respondents strongly realized their lack of knowledge, some were inspired and encouraged to study more about diabetes, and some could understand other professions' work in diabetes care better than before. Over 70% of respondents reported that attending the seminar had changed their daily work or attitude toward patients; the remainder, however, felt unchanged for reasons such as their own lack of experience and ability, and the few chances to aid patients with diabetes. Conclusion: Educational diabetes seminars by and for medical professionals were implemented. The survey of the effects of the seminar has provided further insights into the needs and current situation of education for medical professionals.

A randomized control trial of primary care-based management of type 2 diabetes by a pharmacist in Pakistan

Background

The role of a pharmacist in primary health care settings of Pakistan is still obscure. Thus, we aimed to demonstrate the pharmacist-led improvements in glycemic, blood pressure and lipid controls in type 2 diabetes mellitus (T2DM) patients of Lahore, Pakistan.

Methods

The first open label, randomized control trial conducted at a primary health care facility of Lahore, Pakistan by enrolling 244 uncontrolled type 2 diabetes (hemoglobin A1 c, (HbA1c); 10.85 ± 1.74) patients. The pharmacological intervention included identification of drug related problems, drug interactions, change in dose, frequency and therapy switches in collaboration with physician, while non-pharmacological intervention consisted of diet, lifestyle and behavior counseling. Outcome measures were glycemic (HbA1c), blood pressure and lipid controls.

Results

In intra-group comparison, compared to control arm (C, n = 52), subjects in the intervention arm (I, n = 83) demonstrated significant differences in process outcome measures; baseline vs final, such as HbA1c (C; 10.3 ± 1.3 vs 9.7 ± 1.3, p <  0.001, I; 10.9 ± 1.7 vs 7.7 ± 0.9, p <  0.0001), systolic blood pressure (SBP) (C; 129.9 ± 13.9 vs 136 ± 7.1, p = 0.0001, I; 145 ± 20.4 vs 123.9 ± 9.9 mmHg, p <  0.0001), diastolic blood pressure (DBP) (C; + 4, p = 0.03, I; − 7 mmHg, p <  0.0001), cholesterol (C; 235.8 ± 57.7 vs 220.9 ± 53.2, p = 0.15, I; 224 ± 55.2 vs 153 ± 25.9 mg/dL, p < 0.0001), triglycerides (C; 213.2 ± 86.6 vs 172.4 ± 48.7, p = 0.001, I; 273 ± 119.4 vs 143 ± 31.6 mg/dL, p < 0.0001) and estimated glomerular filtration rate (eGFR) (C; 77.5 ± 18.6 vs 76 ± 14.2, p = 0.5, I; 69.4 ± 21.3 vs 93.8 ± 15.2 ml/min/1.73m², p < 0.0001). Likewise, inter-group improvements were more significant in the subjects of intervention group at final follow up in comparison to control for various process outcome measures; HbA1c (p < 0.001), SBP (p < 0.0001), DBP (p = 0.02), cholesterol (p < 0.0001), triglycerides (p < 0.0001), SCr (p < 0.001), eGFR (p < 0.001). Moreover, both male and female subjects exhibited similar responses towards intervention with similar improvements in outcome measures.

Conclusion

These data suggested that pharmacist intervention in collaboration with physician in primary health care settings may result in significant improvements in glycemic, blood pressure and lipid controls in Pakistani population.

Trial registration

The trial was registered retrospectively with International Standard Registered Clinical/soCial sTudy Number (ISRCTN) registry on July 26, 2017 under nutritional, metabolic, endocrine category with assigned registration # ISRCTN22657497 and can be assessed at 10.1186/ISRCTN22657497

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4274-z) contains supplementary material, which is available to authorized users.

Long-term effectiveness of a type 2 diabetes comprehensive care program. The CAIPaDi model

AIMS

To evaluate the effectiveness of a comprehensive care program to achieve and maintain goals in patients with type 2 diabetes.

METHODS

The CAIPaDi program includes 9 interventions delivered in 7 h. It seeks to achieve metabolic goals, identify and resolve barriers that would make implementation difficult, and provide self-efficacy and empowerment to patients by identifying personal profiles to establish individualized strategies. The program consists of a 4 intervention visits (1, 2, 3, and 4 months) and two follow up visits (12 and 24 months). Outcomes are compared between every visit. Main outcome was the attainment of the USA National Committee for Quality Assurance treatment goals.

RESULTS

1104 patients completed the first 4 visits, 545 the 12 month evaluation, and 218 the 24 month evaluation. After the conclusion of the four monthly sessions, 80.6% had HbA1c <7%, 72.1% had BP <130/80 mmHg and 71.6% had LDL- cholesterol <100 mg/dl. After twelve months, the percentage of goals achieved were 65.9%, 67.7% and 43.3% respectively (p < 0.001). For the 2-year evaluation the percentages were 61.0%, 70.6%, and 40.8% respectively (p < 0.001). All patients had renal, eye, foot and dental evaluations. Empowerment and quality of life showed significant changes; anxiety and depression scores remained low at annual follow-ups.

CONCLUSIONS

The CAIPaDI program results in sustained improvement and maintenance of treatment goals.

Are the resources adoptive for conducting team-based diabetes management clinics? An explorative study at primary health care centers in Muscat, Oman

AimThe aim of this study is to explore the perceptions among primary health center staff concerning competencies, values, skills and resources related to team-based diabetes management and to describe the availability of needed resources for team-based approaches. BACKGROUND: The diabetes epidemic challenges services available at primary health care centers in the Middle East. Therefore, there is a demand for evaluation of the available resources and team-based diabetes management in relation to the National Diabetes Management Guidelines. METHOD: A cross-sectional study was conducted with 26 public primary health care centers in Muscat, the capital of Oman. Data were collected from manual and electronic resources as well as a questionnaire that was distributed to the physician-in-charge and diabetes management team members.FindingsThe study revealed significant differences between professional groups regarding how they perceived their own competencies, values and skills as well as available resources related to team-based diabetes management. The perceived competencies were high among all professions. The perceived team-related values and skills were also generally high but with overall lower recordings among the nurses. This pattern, along with the fact that very few nurses have specialized qualifications, is a barrier to providing team-based diabetes management. Participants indicated that there were sufficient laboratory resources; however, reported that pharmacological, technical and human resources were lacking. Further work should be done at public primary diabetes management clinics in order to fully implement team-based diabetes management.

Multidisciplinary Team-Based Obesity Treatment in Patients With Diabetes: Current Practices and the State of the Science

IN BRIEF Rates of obesity and diabetes are growing, as are their costs. Because the two diseases share many key determinants, the paradigms for their treatment overlap. For both, optimal treatment involves a multidisciplinary team following the Chronic Care Model of health care delivery. Combined treatment programs that include 1) a low-calorie diet individualized to patients' preferences, 2) structured exercise that is also tailored to each patient, and 3) psychotherapy induce the largest weight changes in patients with diabetes. Although diet alone can achieve weight loss, exercise and cognitive behavioral therapy components can enhance the effects of dietary modification. A multidisciplinary team that includes a physician with expertise in pharmacotherapy, a nurse and/or nurse practitioner, a dietitian, an exercise physiologist, and a psychologist can provide a comprehensive weight loss program combining the most effective interventions from each discipline.

Antidiabetic plant-derived nutraceuticals: a critical review

Diabetes mellitus (DM) is one of the major health problems in the world, especially amongst the urban population. Chemically synthesized drugs used to decrease the ill effects of DM and its secondary complications cause adverse side effects, viz., weight gain, gastrointestinal disturbances, and heart failure. Currently, various other approaches, viz., diet control, physical exercise and use of antidiabetic plant-derived molecules/foods are advocated to manage DM, as they are economical with fewer or no side effects. This review mainly focuses on antidiabetic plants, chemically characterized plant molecules and plant-based foods in the treatment of DM. Very little science-based evidence is available on the mechanism of action of plant-derived food molecules on the DM targets. Critical DM targets include α-amylase, α-glucosidase, DPP-IV, aldose reductase, PPAR-γ, AMP kinase and GLUT4. In-depth studies carried out on a few of those targets with specific mechanisms of action are addressed in this review. This review may help future researchers in identifying a right plant molecule to treat DM or to develop food formulations for DM management.

The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios

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Interdisciplinary teams (IDTs) should aim to implement a patient-centred approach.

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IDTs can enable improved glycaemic control and reduced cardiometabolic risk.

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Successful IDTs require strong leadership, good communication and shared goals.

The Global Partnership for Effective Diabetes Management has previously recommended the implementation of an interdisciplinary team (IDT) approach to type 2 diabetes (T2DM) management as one of 10 practical steps for health care professionals to help more people achieve their glycaemic goal. This article discusses some of the key contributors to success and also the challenges faced when applying IDT care, by examining case studies and examples from around the world. The real-world practices discussed show that implementing successful interdisciplinary care in diabetes is possible despite significant barriers such as established hierarchal structures and financial resource constraints. Instituting collaborative, integrated working relationships among multiple disciplines under strong leadership, together with enhanced and active communication and improved patient access to appropriate specialties is essential. Patients have a crucial role in the management of their own disease and including them as part of the treatment team is also critical. IDTs in diabetes care improve patient outcomes in terms of control of glycaemia and cardiometabolic risk factors, and decreased risk of diabetes complications. Ensuring access to an appropriate IDT, in whatever form, is paramount to enable the best care to be delivered.

Treatment urgency: The importance of getting people with type 2 diabetes to target promptly

The burgeoning population of individuals with type 2 diabetes provides challenges for management in terms of risk of diabetes-related complications. Early, intensive glycemic control particularly in newly-diagnosed people with type 2 diabetes has been shown to be beneficial in terms of reducing diabetic complications, indeed various national and international guidelines now routinely recommend intensive blood glucose control as an essential element of type 2 diabetes management. However, despite this, current management of glycemia is suboptimal and not enough people achieve their glucose targets worldwide. The Global Partnership for Effective Diabetes Management believe that an improved understanding of these contributing factors should enable the development of practice and guidance that will promote a drive toward better quality clinical outcomes.

Management of type 2 diabetes mellitus: adherence challenges in environments of low socio-economic status

Background

The efficacy of treatment for clients with diabetes is highly dependent on the individual's ability to manage the disease. Several constraints, such as poverty, illiteracy and insufficient resources (finances and specialised healthcare professionals), especially communities of low socio-economic status, could influence clients’ ability to manage their disease.

Aim

The main aim of this study was to outline the obstacles encountered by individuals with type 2 diabetes mellitus from an urban community with regard to management of their disease.

Setting

The study was conducted at a primary health care facility in the Western Cape, South Africa.

Methods

Ethical clearance was obtained from all relevant authorities. Eight (8) conveniently selected clients with type 2 diabetes mellitus per participating community healthcare centre (six approved centres in total) were invited to take part in focus group discussions. Twenty six clients, 15 females and 11 males, with a mean age of 58.92 years (SD = 7.33), agreed to participate. Audiotaped data were transcribed verbatim followed by content analysis and identification of themes.

Results

Themes that emerged were challenges with: a healthy eating plan, physical activity, financial constraints, other people's understanding of the disease, and service received at the community healthcare centre. Verbatim quotes were used to exemplify the themes.

Conclusion

Clients with type 2 diabetes mellitus experienced several challenges in the management of their disease. These challenges should be addressed to assist with better glycaemic control and to curb the emergence of diabetic complications and their attendant cost implications.

Clinical experience of switching from glargine or neutral protamine Hagedorn insulin to insulin detemir in type 2 diabetes: Observations from the Indian cohort in the A1chieve study

AIM

To explore the clinical safety and effectiveness of insulin detemir (IDet) in a subgroup of Indian patients with type 2 diabetes (T2D) switched from either insulin glargine (IGlar) or neutral protamine Hagedorn (NPH) insulin in the 24-week, non-interventional A1chieve study.

MATERIALS AND METHODS

Indian patients with T2D switching from pre-study IGlaror NPH insulin to IDet were included. Safety and effectiveness outcomes were evaluated by the physicians in local clinical settings.

RESULTS

A total of 102 patients switched from IGlar to IDet (GLA group) and 39 patients switched from NPH insulin to IDet (NEU group). At baseline, the mean glycated hemoglobin A1c (HbA1c) levels were 9.9 ± 1.8% in the GLA group and 9.1 ± 1.2% in the NEU group. No serious adverse drug reactions, serious adverse events, or major hypoglycemic events were reported in either group throughout the study. At baseline and Week 24, 11.8% and 7.5% of patients, respectively, reported overall hypoglycemic events in the GLA group. No hypoglycemic events were reported at Week 24 in the NEU group. At Week 24, the mean HbA1c levels were 7.6 ± 0.9% in the GLA group and 7.3 ± 0.7% in the NEU group. The mean fasting plasma glucose, postprandial plasma glucose and quality of life also appeared to improve over 24 weeks.

CONCLUSION

Switching to IDet therapy from IGlar and NPH insulin was well-tolerated and appeared to be associated with improved glycogenic control in Indian patients.

Changes in the pharmacokinetic of sildenafil citrate in rats with Streptozotocin-induced diabetic nephropathy

Aim

The present investigates deals with the change in the pharmacokinetic of Sildenafil citrate (SIL) in disease condition like diabetic nephropathy (DN).

Method

Diabetes was induced in rats by administering Streptozotocin i.e. STZ (60 mg/kg, IP) saline solution. Assessment of diabetes was done by GOD-POD method and conformation of DN was done by assessing the level of Creatinine, Blood Urea Nitrogen (BUN) and Albuminurea. After the conformation of DN single dose of drug SIL (2.5 mg/kg, p.o.) were given orally and Pharmacokinetic Parameters like [AUC o-t (ug.h/ml), AUC 0-∞, C_max, T_max, Kel, Clast] were estimated in the plasma by the help of HPLC-UV.

Result

There was significant increase (p < 0.01) in the Pharmacokinetic parameters of SIL in DN rat (AUC_0-t, AUC_0-∞, C_max, T_max and T_1/2) compare to normal control rat and significant increase Kel in the DN rat compare to control rat.

Conclusion

The study concluded that there was significant (p < 0.01) increase in the bioavailability of SIL in DN.

Sleep medicine care under one roof: a proposed model for integrating dentistry and medicine

Integrating oral appliance therapy into the delivery of care for sleeprelated breathing disorders has been a challenge for dental and medical professionals alike. We review the difficulties that have been faced and propose a multidisciplinary care delivery model that integrates dental sleep medicine and sleep medicine under the same roof with educational and research components. The model promises to offer distinct advantages to improved patient care, continuity of treatment, and the central coordination of clinical and insurance-related benefits.

Evaluation of the Hypoglycemic Properties of Anacardium humile Aqueous Extract

The antihyperglycemic effects of several plant extracts and herbal formulations which are used as antidiabetic formulations have been described and confirmed to date. The main objective of this work was to evaluate the hypoglycemic activity of the aqueous extract of Anacardium humile. Although the treatment of diabetic animals with A. humile did not alter body weight significantly, a reduction of the other evaluated parameters was observed. Animals treated with A. humile did not show variation of insulin levels, possibly triggered by a mechanism of blood glucose reduction. Levels of ALT (alanine aminotransferase) decreased in treated animals, suggesting a protective effect on liver. Levels of cholesterol were also reduced, indicating the efficacy of the extract in reestablishing the balance of nutrients. Moreover, a kidney protection may have been achieved due to the partial reestablishment of blood glucose homeostasis, while no nephrotoxicity could be detected for A. humile. The obtained results demonstrate the effectiveness of A. humile extracts in the treatment of alloxan-induced diabetic rats. Therefore, A. humile aqueous extract, popularly known and used by diabetic patients, induced an improvement in the biochemical parameters evaluated during and following treatment of diabetic rats. Thus, a better characterization of the medicinal potential of this plant will be able to provide a better understanding of its mechanisms of action in these pathological processes.

Hypoglycemic Effect of Bumelia sartorum Polyphenolic Rich Extracts

Bumelia sartorum (Sapotaceae) is used ethnomedicinally for treatment of several diseases, including diabetes mellitus. The aim of this work was to investigate the hypoglycemic effect of B. sartorum extracts, rich in polyphenolic compounds, and the possible mechanisms of action. Assessment of B. sartorum hypoglycemic activity was performed from the blood glucose level in normoglycemic mice after administration of the extract by oral gavage. The hypothesis that sarco/endoplasmic reticulum Ca2+-ATPase (SERCA) inhibition could prolong the increase in cytoplasmic Ca2+ concentration, thus leading to an increase of insulin release was evaluated. The enzyme inhibition was measured by ATP hydrolysis using SERCA1 isolated from rabbit skeletal muscle. The total content of phenolic compounds was determined by the Folin-Ciocalteau method. The ethyl acetate (EtOAc) partition and F5 fraction obtained from B. sartorum, both of them rich in polyphenolics, were shown to have a hypoglycemic effect on normoglycemic mice, more significant than that of the known antidiabetic drug, glibenclamide used as a standard comparable compound. Both samples significantly inhibited SERCA activity. Different extracts of B. sartorum, rich in polyphenolic compounds, were able to reduce blood glucose in normoglycemic mice and inhibit SERCA activity. SERCA inhibition may be one of the possible mechanisms involved in glucose decrease.

Study of Once Daily Levemir (SOLVE™): insights into the timing of insulin initiation in people with poorly controlled type 2 diabetes in routine clinical practice

AIMS

The aim of this analysis is to determine the timing of insulin initiation in routine clinical practice, especially in relation to glycaemic control and use of oral antidiabetic drugs (OADs).

METHODS

Study of Once Daily Levemir was a 24-week international observational study involving 10 countries which evaluated the safety and effectiveness of initiating once-daily insulin detemir in people with type 2 diabetes mellitus (T2DM) being treated with one or more OADs (clinical trial number NCT00825643 and NCT00740519).

RESULTS

A total of 17 374 participants were enrolled in the study: aged 62 ± 12 years, 53% male, T2DM duration 10 ± 7 years, body mass index 29.3 ± 5.4 kg/m(2) . Pre-insulin HbA1c was 8.9 ± 1.6%. The proportion of patients with HbA1c ≥9.0% ranged from 64% (UK) to 23% (Poland). Pre-insulin OAD treatment included metformin (81%), sulphonylureas (59%), glinides (16%), thiazolidinediones (TZD) (12%), α-glucosidase inhibitors (12%) and dipeptidyl peptidase (DPP)-IV inhibitors (7%). The mean starting dose of insulin detemir for the total cohort was 0.16 ± 0.09 U/kg. Differences in OAD use and insulin doses at initiation were evident among participating countries. The largest proportional changes in OAD prescribing at insulin initiation were seen with glinides (+15%), sulphonylureas (-19%), TZD (-31%) and DPP-IV inhibitors (-28%).

CONCLUSIONS

Despite well-documented benefits of timely glycaemic control and consensus guidelines encouraging earlier use of insulin, considerable clinical inertia exists with respect to initiating appropriate insulin therapy in people with T2DM. Considerable regional differences exist in the timing of insulin initiation and in the use of OADs.

Detemir as a once-daily basal insulin in type 2 diabetes

Background

Insulin detemir, a long-acting basal insulin analog, is labeled for once-daily or twice-daily dosing in patients with type 1 (T1DM) or type 2 (T2DM) diabetes mellitus. Protocols for some earlier clinical studies of detemir evaluated twice-daily dosing, which may have generated the misperception that detemir should be prescribed twice daily for most patients. This review examines pharmacokinetic and pharmacodynamic (PK/PD), observational, and controlled studies that have evaluated once-daily and twice-daily detemir in patients with T2DM to determine the efficacy and safety of once-daily dosing.

Methods

PubMed was searched using the keywords “detemir,” “once daily,” “twice daily,” and “type 2 diabetes” with the limits of clinical trial, human, and English.

Results

Detemir has a relatively flat time–action profile and duration of action of up to 24 hours for patients with T2DM. Once-daily dosing is the most commonly used detemir regimen reported in observational studies, and controlled clinical studies indicate that once-daily dosing controls glycosylated hemoglobin when detemir is administered alone or in combination with a prandial insulin or oral antidiabetes drugs. In comparative clinical trials, detemir had a similar time–action profile and duration of action to another long-acting insulin analog, glargine, with less within-subject variability. Once-daily detemir was associated with no weight gain or less weight gain than comparator regimens. For patients who had not achieved glycemic control with a basal dose of once-daily detemir, adding a prandial insulin provided better glycemic control, less postprandial hypoglycemia, and a lower total daily dose of detemir than twice-daily detemir. Involvement of a multidisciplinary team and the use of a holistic approach for the treatment of T2DM patients are recommended to achieve and maintain the best patient outcomes.

Conclusion

Results from PK/PD, observational, and controlled clinical studies support a once-daily detemir regimen alone or in combination with a prandial insulin or oral antidiabetes drugs.

Health care professionals meeting with individuals with Type 2 diabetes and obesity: Balancing coaching and caution

The burden of diabetes and obesity is increasing worldwide, indicating a need to find the best standard for diabetes care. The aim of this study was to generate a theory grounded in empirical data derived from a deeper understanding of health care professionals' main concerns when they consult with individuals with diabetes and obesity and how they handle these concerns. Tape-recorded interviews were conducted with seven groups and three individual members of a diabetes team in an area of western Sweden. The grounded theory (GT) method was used to analyse the transcribed interviews. A core category, labelled Balancing coaching and caution and three categories (Coaching and supporting, Ambivalence and uncertainty, and Adjusting intentions) emerged. The core category and the three categories formed a substantive theory that explained and illuminated how health care professionals manage their main concern; their ambition to give professional individualised care; and find the right strategy for each individual with diabetes and obesity. The theory generated by this study can improve our understanding of how a lack of workable strategies limits caregivers' abilities to reach their goals. It also helps identify the factors that contribute to the complexity of meetings between caregivers and individuals with diabetes.

Modulatory Effect of Rice Bran and Phytic Acid on Glucose Metabolism in High Fat-Fed C57BL/6N Mice

The effect of dietary feeding of rice bran and phytic acid on the glucose metabolism in high fat-fed C57BL/6N mice fed was investigated. The mice were given with either a high fat diet only (HF group) or a high fat diet supplemented with rice bran (HF-RB group) or phytic acid (HF-PA group) for 7 weeks. The control mice (NC group) received a normal diet. At the end of the experimental period, the HF group exhibited substantially higher blood glucose level than the NC group. However, the HF-RB and HF-PA groups showed a marked decrease in the blood glucose level relative to HF mice. Furthermore, significantly higher glucokinase (GK) activity and lower phosphoenolpyruvate carboxykinase (PEPCK) activity were observed in HF-RB and HF-PA mice compared with that of the NC and HF ones. It was also found that the glucose-6-phosphatase (G6pase) activity and hepatic glycogen concentration were considerably higher in HF-RB and HF-PA groups, respectively, than that of the HF mice. These findings demonstrate that both rice bran and phytic acid could reduce the risk of high fat diet-induced hyperglycemia via regulation of hepatic glucose-regulating enzyme activities.

The Kathmandu Declaration: "Life Circle" approach to prevention and care of diabetes mellitus

OBJECTIVES

To formulate strategies and action plans for the prevention and care of diabetes mellitus as part of the implementation of the International Diabetes Federation (IDF) United Nations Resolution (UNR) 61/225 through a unique concept of a "Life Circle" approach.

METHOD

Consensus following review of evidence available and presented at a meeting convened to achieve the objective co-chaired by the IDF President and President elect and diabetologists from several countries in the IDF regions.

CONCLUSIONS

The Kathmandu Declaration presents the concept of a "Life Circle" approach to prevention and care of diabetes--a continuum beginning from preconception, pregnancy, infancy and childhood to adult life in an integrated manner. Emphasis is on the benefits on entering the circle at any point and formulates guidelines that could be incorporated in any national diabetes prevention and care programme, indicating the interactive role of all known aetiological factors.

The meaning of a consultation with the diabetes nurse specialist

OBJECTIVE

The aim of this study was to elucidate the essential meaning of a consultation between diabetes nurse specialists and patients to gain a deeper understanding of the patients' experiences.

METHODS

Twenty patients with type 2 diabetes were interviewed about their experience of a consultation at an annual check-up with the diabetes nurse specialist. A phenomenological hermeneutic method was used in the analysis and interpretation of the text.

RESULTS

The patient's experience of a consultation was interpreted as manifestation of hold on the disease control. This means a safeguard to continue daily life shown in the four themes being controlled, feeling exposed, feeling comfortable, and feeling prepared.

CONCLUSION

The patients' experiences of a consultation with the diabetes nurse specialist became the basis for a health maintenance process in dealing with critical health-disease aspects. IMPLICATIONS TO PRACTICE: In a consultation, professionals have to take into account the potential emotional turbulence that disease progression can mean to a patient. Diabetes care implies patient dependence on support to avoid a potential self-management insufficiency and call attention to professionals' time for listening to patients' perceptions.

Assessment of risk factors in diabetic foot ulceration and their impact on the outcome of the disease

AIMS

The current study aims to identify risk factors for diabetic foot ulcer and their impact on the outcome of the disease.

METHODS

Three hundred diabetic patients were enrolled in the study. One hundred eighty subjects with diabetic foot ulcer and 120 diabetic controls without foot lesions. All expected risk factors were studied in all patients and after a follow up period, patients with diabetic foot ulcer were classified into group A (patients with healed ulcers) and group B (patients with persistent ulcer or ended by amputation). The risk factors were reanalyzed in both groups to find out their impact on the outcome of the disease.

RESULTS

The following variables were significant factors for foot ulceration: Male gender (P=0.009), previous foot ulcer (P=0.003), peripheral vascular disease (P=0.004), and peripheral neuropathy (P=0.006). Also lack of frequent foot self-examination was independently related to foot ulcer risk. The outcome was related to longer diabetes duration (P=0.004), poor glycaemic control (P=0.006) and anaemia (P=0.003) and presence of infection (P<0.001).

CONCLUSIONS

Peripheral vascular disease and peripheral neuropathy together with lack of foot self-examination, poor glycaemic control and anaemia are main significant risk factors for diabetic foot ulceration.

Seasonal variation in fasting glucose and HbA1c in patients with type 2 diabetes

Seasonal variations in fasting glucose and HbA1c levels in 638 diabetic patients (attending a primary care diabetic clinic during 2003-2007) were examined and found to be significantly higher in colder than in warmer months. Moreover, there were apparent peaks in fasting glucose levels after Christmas and Easter months. This study provides further evidence of monthly fluctuations in glycemic control, underscoring the need to consider seasonal/cultural effects when managing diabetic patients.