A standard set of person-centred outcomes for diabetes mellitus: results of an international and unified approach

AIMS

To select a core list of standard outcomes for diabetes to be routinely applied internationally, including patient-reported outcomes.

METHODS

We conducted a structured systematic review of outcome measures, focusing on adults with either type 1 or type 2 diabetes. This process was followed by a consensus-driven modified Delphi panel, including a multidisciplinary group of academics, health professionals and people with diabetes. External feedback to validate the set of outcome measures was sought from people with diabetes and health professionals.

RESULTS

The panel identified an essential set of clinical outcomes related to diabetes control, acute events, chronic complications, health service utilisation, and survival that can be measured using routine administrative data and/or clinical records. Three instruments were recommended for annual measurement of patient-reported outcome measures: the WHO Well-Being Index for psychological well-being; the depression module of the Patient Health Questionnaire for depression; and the Problem Areas in Diabetes scale for diabetes distress. A range of factors related to demographic, diagnostic profile, lifestyle, social support and treatment of diabetes were also identified for case-mix adjustment.

CONCLUSIONS

We recommend the standard set identified in this study for use in routine practice to monitor, benchmark and improve diabetes care. The inclusion of patient-reported outcomes enables people living with diabetes to report directly on their condition in a structured way.

Health Literacy in Diabetes management: A priority in health care

Background

Glycemic control and self-management of diabetes are influenced by a range of factors, including health literacy - the ability to access, understand, appraise, and use health information. This study explored associations between domains of health literacy (HL), glycemic control and perceived general health in people with diabetes.

Methodology

Cross-sectional study, with 453 people with diabetes,attending the Portuguese Diabetes Association (APDP). We collected information on HL, demographics, glycemic control and self-perception of health. HL was assessed using the Health Literacy Questionnaire. Descriptive and correlational analysis were performed.

Results

85.4% consider Feeling understood and supported by healthcare providers but only 54.1% have the Ability to actively engage with healthcare providers and 27.8% feel the Ability to find good health information,66.5% consider Having sufficient information to manage my health but only 38.7% are Understanding health information well enough to know what to do and 28.5% refer the Ability to find good health information. Higher HL scores were associated with better glycemic control and more positive perception of general health(GH) across the following domains: Having sufficient information to manage my health, Appraisal of health information, Ability to find good health information, Actively managing my health and social support for health. The domains Ability to actively engage with healthcare providers and Navigating the healthcare system were also associated with more positive perception of GH. Associations achieved either p < 0.001 or p < 0.05. Considering HL levels, a statistically significant negative association was found with the levels of HbA1c and positive association with perceived general health, even for functional HL.

Conclusions

The results emphasize the importance of improving the level of HL of people with diabetes in order to improve glycemic control and the perceive General Health

Key messages

Health literacy is critical for diabetes self-management. People with diabetes need to understand and use health information to promote well-being and diabetes control.

Glycaemic threshold for diabetes-specific retinopathy among individuals from Saudi Arabia, Algeria and Portugal

We studied the glycaemic threshold and prevalence of diabetic retinopathy in screen-detected diabetes in Saudi Arabia, Algeria and Portugal. The prevalence of diabetes-specific retinopathy started to increase at an HbA1c level of 6-6.4% (42-47 mmol/mol) and in individuals with HbA(1c) >7.0% the prevalence was 6.0%.

Pleural effusion: what lies underneath?

Malignant mesothelioma is a tumour of serous surfaces mainly arising at the pleura or the peritoneum. The diagnosis encompasses multiple problems as there is no pathognomonic hallmark for the disease, there are multiple histological types and the differentiation from other tumours, such as adenocarcinoma or metastatic pleural disease, can represent quite a challenge. Usually a diagnosis of malignant mesothelioma carries a dismal prognosis with scarce therapeutical options.The present report concerns a patient with a diagnosis of malignant pleural mesothelioma with endobronchial extension. Biopsy specimens were obtained through fibreoptic bronchoscopy and blind needle pleural biopsy. The final diagnosis was only possible after careful histological evaluation with a combination of immunohistochemical markers.

Comparison of whole-blood glutathione peroxidase activity, levels of serum selenium, and lipid peroxidation in subjects from the fishing and rural communities of "Rabo de Peixe" village, San Miguel Island, the Azores' Archipelago, Portugal

The activity of glutathione peroxidase (GSH-Px), serum selenium (Se), and thiobarbituric acid reactive substances (TBARS) were measured in the whole blood of 148 healthy adults aged 20-60 yr from the fishing and rural communities of "Rabo de Peixe," The Azores, Portugal. The subjects did not live in the same household and had different socioeconomic profiles and dietary habits. The serum lipid profile and selected life habits were also considered in this study. No significant differences in the activity of GSH-Px were found in the interpopulation or intrapopulation analyses, classified by age or lipid profile. An age-dependent GSH-Px increase was noted in the younger male (M) subgroups (20-39 yr). The Se levels were higher in fishers (f) of both genders (M, F) than in subjects living in the rural (r) environment: 110+/-25 microg/L (f, M), 89+/-20 microg/L (f, F), 88+/-22 microg/L (r, M) and 80+/-17 microg/L (r, F). In the fishers, but not in the rural population, Se was higher in the males, but it did not show significant variation with age. The levels of TBARS were lower in the f than in the r male group. The Se level was lower and TBARS higher in the hyperlipemic women in the f group, compared to the corresponding controls. Our results suggest that the fishers (mainly men) show a better antioxidant status than that of their rural counterparts, due to differences in dietary habits between the study populations and between genders.

[Aplastic anemia. Alternative treatment by bone marrow transplantation]

We report a case of a 25-year-old woman, with the diagnosis of severe aplastic anemia without a histocompatible sibling donor for bone marrow transplantation. The patient has been treated successfully with a combination of two immunosuppressive agents, cyclosporine and antilymphocyte globulin, after not responding to primary therapy with corticosteroids and growth factors. She showed a complete response to treatment, with transfusional independence, after a follow-up of 14 months. The pathophysiology of aplastic anemia, the mechanism of action and secondary effects of these treatments are discussed.

[Hodgkin's disease in a patient with sarcoidosis]

We present the case of a 37 years old woman with mediastinal lymphadenopathy since the age of 13. At de age of 14, the patient presented a left cervical lymphadenopathy and the onset of episodic nodose erythema. One year later, histological examinations of an enlarged lymph node revealed sarcoidal granulomata. Corticotherapy was prescribed and the patient became asymptomatic. At the age of 31, the patient complained of asthenia and fever with left parotid tumefaction. Corticotherapy was therefore resumed with good response. Three years later, the patient presented left parotid tumefaction, left cervical lymphadenopathy and painful eye congestion. The patient was submitted to parotidectomy and lymphadenectomy. One month later, an ulceration with progressive enlargement developed in the surgical scar, and the patient suffered from asthenia, anorexia, weight loss, fever, nocturnal sweating and cervical and axillary lymphadenopathy. At Santa Maria Hospital, the patient's condition was diagnosed as Hodgkin's disease, mixed cellularity subtype, stage II Bb with local cutaneous involvement. The prescribed treatment was MOPP/ABV-8 cycles- and complete remission was achieved. The patient is still asymptomatic after a follow-up of 6 years. Cutaneous involvement in Hodgkin's disease is rare and generally associated with advanced disease and poor prognosis, facts that did not occur in this case. The differential diagnosis between sarcoidosis and sarcoid reaction in Hodgkin's disease, the accidental coexistence of both entities and the evolution of sarcoidosis into lymphoma are also discussed. The sarcoidosis immune defect may be the result of the same immune disorder. No relationships between sarcoidosis and cutaneous involvement in Hodgkin's disease were found in the literature.

[Treatment of acute promyelocytic leukemia with trans-retinoic acid. Experience of the Santa Maria Hospital, Medical School of Lisbon]

Acute promyelocytic leukemia (APL) is a rare subtype of acute myelogenous leukemia that is usually associated with a fatal hemorrhagic diathesis. All trans-retinoic acid (ATRA) is an active metabolite of vitamin A that differentiates the malignant cell clone, corrects the coagulopathy, and induces complete remission in the vast majority of patients with APL. Between June 1992 and September 1993, 8 patients with APL (4 previously untreated, 3 in first relapse and 1 in second relapse) received ATRA. Complete remission was achieved in 7 patients; in 5 with ATRA alone and in 2 with ATRA followed by cytotoxic chemotherapy due to the development of asymptomatic hyperleukocytosis. The earliest signs of response were the correction of the coagulopathy and an increase in the white blood cell count. Sequential morphological and immunophenotypical analyses of the bone marrow revealed differentiation of the malignant cell clone, in the absence of bone marrow hypoplasia. 4 of 5 patients treated only with ATRA until complete remission had late leukopenia. The most frequent adverse effects were dryness of skin and mucosae, hypertrigliceridemia and hypercholesterolemia, and a moderate increase in liver transaminases. An increase in the white blood cell count was common, and in two cases exceeded 35.0 x 10(9)/l. One of these patients developed multiple thrombosis of the extremities after cytotoxic chemotherapy. We frequently observed an increase in lactic dehydrogenase levels that was concomitant with the peak in the white blood cell count. The only patient on whom complete remission was not achieved was 60 years old, had chronic obstructive pulmonary disease, and died in the third week of therapy with a pulmonary distress syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

Oxygen radical generation by Maillard compounds

Amino sugars such as galactosamine are hepatotoxic. It has been verified that toxic hepatitis induced by galactosamine is similar to that of CCl4 poisoning, and that both were inhibited by O2* scavengers. Fructosamine results from the union of glucose with the epsilon-amine of lysine. A test for fructosamine quantification is based on nitroblue tetrazolium (NBT) reduction, in which O2- is involved, the reduction being inhibited in the presence of superoxide dismutase (SOD). Given these facts, we attempted to elucidate if galactosamine and glucosamine reduce NBT and if that reduction is inhibited by SOD. This was confirmed. Subsequently, we incubated aminoacids (glycine, lysine, alanine) with glucose and galactose for 7 days and studied the action of the incubation products on NBT, using amino acids and sugars as controls. We found that NBT reduction increases proportionally to the length of incubation time of glucose/galactose with lysine, but not with other amino acids. Reduction of NBT by the Amadori compounds formed is inhibited by SOD. We suggest that oxygen radical generation by Amadori compounds must be taken into consideration as one cause of damage in diabetes of long duration.

Superoxide radical generation by Amadori compounds

Several D-sugars were incubated with L-lysine or with L-arginine for 10 days. The resulting compounds are able to reduce nitrobluetetrazolium (NBT). This is prevented by superoxide dismutase (SOD), indicating that the superoxide radical is generated by the resulting Amadori compounds. The formation of superoxide radical in vivo, as a result of nonenzymatic glycosylation of proteins, may be considered to be a contributory factor to the appearance of chronic complications of diabetes.