15. Diabetes Advocacy

The Differences of N–Acetyl–β–Glucosaminidase and β2 Microglobulin levels in Patients with and without Early Diabetic Nephropathy

Diabetic Nephropathy (DN) is becoming the most serious microvascular complication, which be marked by the presence of persistent albuminuria. N–asetil–β–glucosaminidase is dominant lyzosom enzyme in the renal tubule epitel. β2 microglobulin is low molecular weight protein which produced by major histocompatibility complex class 1 (MHC-1) expressed cell in all nucleated cell. N–asetil–β–glucosaminidase and β2 microglobulin could be new usefull marker for early DN. Analytic observational study with cross sectional approach was conducted in May – July 2019 involving 27 non diabetic patients (K1), 27 diabetic patients without DN (K2) and 27 diabetic patients with early DN (K3) at the Clinical Pathology department of Faculty of Medicine, Diponegoro University and Diabetic Clinic. Data include age, gender, fasting blood glucose, blood preasure and urine albumin creatinine ratio. N–asetil–β–glucosaminidase level between groups were analyzed using Anova, β2 microglobulin level between groups using Kruskal Wallis, p<0.05 were considered significant. There are significant differences in levels of N–asetil–β–glucosaminidase between K1 and K2 (p =0.01), K1 and K3 (p =< 0.01), K2 and K3 (p = 0.03) and β2 microglobulin  between K1 and K2 (p = 0.02), K1 and K3 (p =< 0.01), K2 and K3 (p< 0.01). N-acetyl-β-glucosaminidase and β2 microglobulin levels were higher in K2 compared to K1 and increased higher in K3 compared to K1 and K2. N-acetyl-β-glucosaminidase and β2 microglobulin can be used as an alternative marker for early DN. 

Factors related to barriers and medication adherence in patients with type 2 diabetes mellitus: a cross-sectional study

Purpose

Evidence has shown that 50% of patients, including type 2 diabetes mellitus (DM), are non-adherent to the prescribed antidiabetic medication regimen. Some barriers lead to nonadherence in people with DM type 2. The study aimed to identify factors related to adherence in patient with DM and to assess the correlation between barriers to adherence type 2 DM patients.

Methods

The cross-sectional study was conducted in 63 primary healthcare centers in Surabaya, Indonesia. Patients with DM type 2 were recruited between April and September 2019 using convenient sampling technique. Ethics approval was obtained (80/EA/KEPK/2019).

Results

A total of 266 patients with type 2 DM participated in this study. Of the respondents, 201 (75.2%) were female. Unwanted drug effects, changes in medication regimens, and refilling the prescription when the drugs run out were most reported factors that affected adherence. Spearman correlations and linear regression tests were used to examine the relationship between barriers to medication adherence, and education with medication adherence. A significant difference was observed between the level of education and adherence (p = 0.031). The results showed an association between barriers to medication and adherence to medication (r = 0.304; p < 0.001) which was confirmed in regression analysis (R = 0.309, R square = 0.095, p <0.001).

Conclusions

Barriers to adherence are common and affect adherence to therapy. It is essential to expand the roles of health care professionals in the community to include counseling, barrier-monitoring, education, and problem-solving to improve patient medication adherence.

Tibetan Medicines for the Treatment of Diabetic Nephropathy

As an important part of the traditional Chinese medicine system, Tibetan medicine has its unique treatment methods for diabetes mellitus and its complications. Diabetic nephropathy (DN) is one of the most serious diabetic microvascular diseases. Tibetan medicine believes that the occurrence of DN is closely related to renal function changes, and it can be effectively prevented and treated by improving renal lesions. In this paper, we consult ancient books of Tibetan medicine and summarize the medicines that treat kidney disease in the Tibetan medicine system. The Chinese name, English name, and Latin name of these drugs were searched as keywords in the online database. Thirty-four drugs were found for the treatment of DN. The most commonly used were Amomum kravanh, Terminalia chebula, and Tribulus terrestris, and we introduced the traditional uses and modern pharmacological activities of these drugs. The results indicate that Tibetan medicines for kidney disease could be used as potential candidate drugs for DN; they would expand the range of medications for DN and provide a new idea for the treatment of DN.

Development of an intervention to facilitate implementation and uptake of diabetic retinopathy screening

BACKGROUND

'Implementation interventions' refer to methods used to enhance the adoption and implementation of clinical interventions such as diabetic retinopathy screening (DRS). DRS is effective, yet uptake is often suboptimal. Despite most routine management taking place in primary care and the central role of health care professionals (HCP) in referring to DRS, few interventions have been developed for primary care. We aimed to develop a multifaceted intervention targeting both professionals and patients to improve DRS uptake as an example of a systematic development process combining theory, stakeholder involvement, and evidence.

METHODS

First, we identified target behaviours through an audit in primary care of screening attendance. Second, we interviewed patients (n = 47) and HCP (n = 30), to identify determinants of uptake using the Theoretical Domains Framework, mapping these to behaviour change techniques (BCTs) to develop intervention content. Thirdly, we conducted semi-structured consensus groups with stakeholders, specifically users of the intervention, i.e. patients (n = 15) and HCPs (n = 16), regarding the feasibility, acceptability, and local relevance of selected BCTs and potential delivery modes. We consulted representatives from the national DRS programme to check intervention 'fit' with existing processes. We applied the APEASE criteria (affordability, practicability, effectiveness, acceptability, side effects, and equity) to select the final intervention components, drawing on findings from the previous steps, and a rapid evidence review of operationalised BCT effectiveness.

RESULTS

We identified potentially modifiable target behaviours at the patient (consent, attendance) and professional (registration) level. Patient barriers to consent/attendance included confusion between screening and routine eye checks, and fear of a negative result. Enablers included a recommendation from friends/family or professionals and recognising screening importance. Professional barriers to registration included the time to register patients and a lack of readily available information on uptake in their local area/practice. Most operationalised BCTs were acceptable to patients and HCPs while the response to feasibility varied. After considering APEASE, the core intervention, incorporating a range of BCTs, involved audit/feedback, electronic prompts targeting professionals, HCP-endorsed reminders (face-to-face, by phone and letter), and an information leaflet for patients.

CONCLUSIONS

Using the example of an intervention to improve DRS uptake, this study illustrates an approach to integrate theory with user involvement. This process highlighted tensions between theory-informed and stakeholder suggestions, and the need to apply the Theoretical Domains Framework (TDF)/BCT structure flexibly. The final intervention draws on the trusted professional-patient relationship, leveraging existing services to enhance implementation of the DRS programme. Intervention feasibility in primary care will be evaluated in a randomised cluster pilot trial.

Glycosylated Hemoglobin in Subjects Affected by Iron-Deficiency Anemia

Previous studies have suggested that iron-deficiency anemia affects glycosylated hemoglobin (HbA1c) measurements, but the results were contradictory. We conducted a retrospective case-control study to determine the effects of iron deficiency on HbA1c levels. Starting with the large computerized database of the Italian Hospital of Desio, including data from 2000 to 2016, all non-pregnant individuals older than 12 years of age with at least one measurement of HbA1c, cell blood count, ferritin, and fasting blood glucose on the same date of blood collection were enrolled. A total of 2,831 patients met the study criteria. Eighty-six individuals were diagnosed with iron-deficiency anemia, while 2,745 had a normal iron state. The adjusted means of HbA1c were significantly higher in anemic subjects (5.59% [37.37 mmol/mol]), than those measured in individuals without anemia (5.34% [34.81 mmol/mol]) (P<0.0001). These results suggest that clinicians should be cautious about diagnosing prediabetes and diabetes in individuals with anemia.

Sustaining quality in the community: trends in the performance of a structured diabetes care programme in primary care over 16 years

AIM

To examine the quality of care delivered by a structured primary care-led programme for people with Type 2 diabetes mellitus in 1999-2016.

METHODS

The Midland Diabetes Structured Care Programme provides structured primary care-led management. Trends over time in care processes were examined (using a chi-squared trend test and age- and gender-adjusted logistic regression). Screening and annual review attendance were reviewed. A composite of eight National Institute for Health and Care Excellence-recommended processes was used as a quality indicator. Participants who were referred to diabetes nurse specialists were compared with those not referred (Student's t-test, Pearson's chi-squared test, Wilcoxon-Mann-Whitney test). Proportions achieving outcome targets [HbA_1c ≤58 mmol/mol (7.5%), blood pressure ≤140/80 mmHg, cholesterol <5.0 mmol/l] were calculated.

RESULTS

Data were available for people with diabetes aged ≥18 years: 1998/1999 (n=336); 2003 (n=843); 2008 (n=988); and 2016 (n=1029). Recording of some processes improved significantly over time (HbA_1c , cholesterol, blood pressure, creatinine), and in 2016 exceeded 97%. Foot assessment and annual review attendance declined. In 2016, only 29% of participants had all eight National Institute for Health and Care Excellence processes recorded. A higher proportion of people with diabetes who were referred to a diabetes nurse specialist had poor glycaemic control compared with those not referred. The proportions meeting blood pressure and lipid targets increased over time.

CONCLUSIONS

Structured primary care led to improvements in the quality of care over time. Poorer recording of some processes, a decline in annual review attendance, and participants remaining at high risk suggest limits to what structured care alone can achieve. Engagement in continuous quality improvement to target other factors, including attendance and self-management, may deliver further improvements.