Primary Care Diabetes

Editorial Board

2009-11-01

Diabetes therapy and cancer; diabetes and CVD in people with severe mental illness—Thoughts from Vienna

Rhys Williams — 2009-11-23

Iatrogenic disease should be our worst nightmare. Having said that, I doubt whether many undergraduate or postgraduate programmes or programmes of continuing professional development address iatrogenic disease under that title. However, at least we have stopped referring to “side effects” – a rather meek term for events that can, in some cases, be devastating. We now refer to “adverse effects”, a term which has just a little more bite to it.

Smoking and diabetes—The double health hazard!

Robert H. Fagard, Peter M. Nilsson — 2009-10-30

Abstract: Smoking is a predictor of the transition from normoglycaemia to impaired fasting glucose and increases the risk of type 2 diabetes, independent from possible confounders. In patients with diabetes as in non-diabetics, smoking is a significant and independent risk factor for all-cause mortality and for mortality from cardiovascular disease and corononary heart disease, as well as for aggregates of fatal and non-fatal cardiovascular events. There is little doubt that smoking is a risk factor for coronary heart disease, but this risk appears to be stronger than the risk for stroke in diabetics. Pathophysiological mechanisms by which smoking causes glucose intolerance and worsens clinical outcomes in established diabetes include greater insulin resistance, impaired beta-cell function and insulin secretion, chronic low-grade inflammation, endothelial dysfunction, as well as interacting indirectly with other factors known to aggravate diabetes and lifestyle factors. Smoking cessation programs are of great importance for primary care specialists dealing with diabetes.

Identification of persons with dysglycemia: Terminology and practical significance

David F. Williamson, K.M. Venkat Narayan — 2009-09-18

Abstract: Allocating scarce resources for dysglycemia intervention requires identification of persons who will benefit. Identification has two steps: screening followed by diagnosis. Lowering a screening test's cut-off score identifies more persons with dysglycemia, but causes more normoglycemic persons to receive diagnostic testing. Raising a test's cut-off score reduces needless diagnostic testing, but increases the number falsely identified as not having dysglycemia. With limited budgets for intervention, raising a screening test's cut-off score may be appropriate. With ample budgets, lowering the test's cut-off score may be appropriate. Screening tests are most efficient in populations with high prevalence of dysglycemia.

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

Emad Naeem Hokkam — 2009-09-24

Abstract: 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.

Diabetes care in Ireland: A survey of general practitioners

2009-10-19

Abstract: Aim: To investigate the organisation of diabetes care in general practice in Ireland and identify areas for future development.Methods: Survey of a representative sample of 600 general practitioners (GPs). The questionnaire contained closed and open-ended questions addressing 4 topics; characteristics of the practice, diabetes care delivery, use of services and opportunities for developing diabetes care.Results: The response rate was 44% (n=262). There were an additional 86 responses to a follow-up shortened version of the survey resulting in a 58% response rate for 9 key questions. The majority of respondents were from an urban (43%, n=112) or a mixed area (39%, n=101) and 19% of practices were single-handed (n=66). The reported prevalence in participating practices was 0.7% for Type 1 diabetes and 2.8% for Type 2 diabetes. Forty-five percent of GPs maintained a diabetes register (n=157) while 53% reported using guidelines (n=140). A formal call recall system was reported by 30% (n=78) with a further 20% (n=54) reporting a regular if informal approach to calling patients for review. With regard to the use of diabetes related services 63% reported direct access to a dietician (n=165), 57% direct access to chiropody services (n=149) and 89% had direct access to retinopathy screening (n=234). There was a significant association between maintaining a diabetes register and other aspects of care delivery such as engaging in formal recall (p<0.001), using guidelines (p<0.001) and a declared special interest in diabetes (p=0.001). Of a number of choices 75% of GPs thought that training was the principal opportunity for improving diabetes care. In response to the open-ended questions GPs cited lack of resources, time constraints and workload as barriers to effective care delivery.Conclusions: Delivery of diabetes care in Ireland remains largely unstructured. Key challenges to improving diabetes care appear to extend to the system and organisational level of care delivery.

Prevalence and clinical profile of autosomal dominant type 2 diabetes from a diabetes centre in India

2009-11-05

Abstract: Aims: To study the prevalence, and clinical profile of autosomal dominant (AD) inherited forms of type 2 diabetes mellitus (T2DM).Methods: Detailed pedigree charts were drawn on 510 consecutive T2DM subjects attending a tertiary care diabetes centre in South India. Clinical and biochemical features of T2DM subjects with and without AD inheritance were compared.Results: Overall, 36.1% of T2DM had one parent with diabetes, in 10.6%, both parents had diabetes and 10.2% had features of AD. Age at diagnosis of diabetes was the lowest among AD group compared to other groups (p for trend <0.001). Only 22.6% of T2DM with AD inheritance had age at diagnosis of diabetes below 25 years and in 26.4%, it was diagnosed above 45 years. There were no significant differences in the clinical features, including prevalence of diabetic complications, between T2DM with and without AD inheritance.Conclusions: In this clinic-based study, 10.2% of T2DM subjects had evidence of AD inheritance. While the AD cases occurred at younger age, older age at diagnosis was not uncommon. Clinical features, including complications, did not differ between the T2DM patients with or without AD.

Perceptions of heart attack risk amongst individuals with diabetes

2009-11-06

Abstract: Aim: Individuals with diabetes are at increased risk of cardiovascular disease (CVD). There is good evidence that this risk can be reduced by pharmacotherapies and lifestyle modification. Despite this, knowledge of CVD risk amongst individuals with diabetes remains poor. We undertook a qualitative study to investigate lay perceptions of heart attack risk amongst individuals with diabetes in order to gather information about underlying perceptions concerning risk and risk reduction strategies.Methods: We conducted three focus groups in Oxford using an open-ended question map. Content analysis was performed to identify recurring themes, similar patterns, distinctions and supportive quotations.Results: Concern about having a heart attack varied widely. A commonly held view was that a 10-year heart attack risk of 10% or greater was high and being aware of one's risk was important so that lifestyle changes or other interventions could be implemented. Participants consistently viewed physical activity as potentially harmful. Almost all participants sought healthcare and lifestyle advice from their primary healthcare providers in the first instance, preferring this to information in the lay press or government campaigns.Conclusion: The focus groups have allowed us to better understand lay perceptions of, and underlying assumptions about, CVD risk. These findings may be of use when discussing CVD risk and risk reduction strategies in primary care.

Use of a patient linked data warehouse to facilitate diabetes trial recruitment from primary care

2009-07-15

Abstract: Recruitment into clinical trials from primary care may be difficult. Our aim was to use the Secure Anonymised Information Linkage (SAIL) databank to identify potential participants for two factitious trials. We identified 284 and 711 participants for each study (population=250,086). This method appears promising in identifying trial participants.

Failure to control risk factors among patients with type 2 diabetes; experience from a Greek cohort

Anastasios Kollias, Ioannis A. Bliziotis, Apostolos Xilomenos, Apostolos Tolis — 2009-09-01

Abstract: We reviewed the records of 313 diabetic patients attending a diabetes clinic for at least two years. Despite improvements in the control rates of cardiovascular risk factors, only 8.9% of the patients reached all the metabolic target goals simultaneously at the end, indicating a gap between guidelines and clinical practice.

A survey of treatment practices in diabetic peripheral neuropathy

Carl J. Possidente, Rup Tandan — 2009-10-05

Abstract: Objective: To evaluate provider practices for identification and treatment of painful diabetic peripheral neuropathy (DPN).Methods: A questionnaire was distributed to healthcare providers attending educational programs in New England.Results: The survey was completed by 357 providers. Although generally ineffective in neuropathic pain, non-steroidal anti-inflammatory drugs were prescribed by 31% of providers. Only 57% providers used a quantitative pain scale to evaluate pain. The effectiveness of medications was assessed at least frequently by 70% of providers and at every visit by 22% providers.Conclusion: The results reiterate the need for routinely monitoring patients with painful DPN and using appropriate pain scales.

Waist circumference in primary care

Pam Brown — 2009-10-30

Abstract: Current literature suggests that waist circumference may be marginally better than BMI as a surrogate marker for total body fat and can identify thinner people with increased visceral adipose tissue and increased cardiometabolic risk. This commentary explores the use of WC in primary care, including how and when to measure, and how to use the results.

Society News

2009-11-23