Orthostatic hypertension in patients with type 2 diabetes

OBJECTIVE: The prevalence and clinical importance of orthostatic hypertension (OHT) in diabetic patients has not been elucidated, in contrast to orthostatic hypotension, which is occasionally found in diabetic patients with autonomic neuropathy. RESEARCH DESIGN AND METHODS: The prevalence and severity of orthostatic hypertension was investigated in 277 Japanese male patients with type 2 diabetes, including 90 hypertensive patients and 128 nondiabetic age-matched male subjects. Patients treated with antihypertensive drugs were excluded from the study. OHT was defined as an increase in diastolic blood pressure (DBP) from <90 to >or=90 mmHg and/or an increase in systolic blood pressure (SBP) from <140 to >or=140 mmHg after standing from supine position. Clinical profiles and several serum biochemical parameters were determined in addition to chest X-rays and electrocardiograms. RESULTS: The prevalence of OHT in normotensive and hypertensive diabetic patients was significantly higher than in control subjects (12.8 vs. 1.8%, P < 0.01, for normotensive patients; 12.6 vs. 11.1%, not significant, for hypertensive patients). Orthostasis induced a mean increase of 6.8 +/- 11.4 mmHg in SBP and 9.1 +/- 5.2 mmHg in DBP in diabetic patients with OHT compared with those without OHT (-1.0 +/- 9.0 and 3.8 +/- 6.6 mmHg, respectively). Vibration sensation in the lower limb was reduced in diabetic patients with OHT, but the percent coefficient of variation of RR interval, cardio-to-thoracic ratio on chest X-ray, and serum triglyceride levels were higher in these patients compared with normotensive diabetic patients without OHT. CONCLUSIONS: Orthostatic hypertension is a novel complication in normotensive diabetic patients and may associate with early stage neuropathy and development of sustained hypertension.     

糖尿病护理门诊患者失随访影响原因的研究

目的:调查糖尿病护理门诊患者失随访原因。方法:自某三级甲等医院护理门诊系统中筛选6个月未按时随访的203例患者为研究对象,电话调查患者对随访的主观认识和未按时随访的原因。同时抽取规律随访患者91例作为对照,电话询问对随访的主观认识。分析患者客观资料,与失随访与否作相关性回归分析。结果:患者对随访的主观态度(OR=60.67)、患者独自随访能力(OR=0.05)、随访路程耗时(OR=1.03)、并发症严重程度(OR=0.26)与失随访存在相关性,具有统计学意义。结论:具有失随访特征的患者对于护理门诊随访耐受性较差,应针对该人群探讨新的方式。     

The effectiveness of a diabetes nurse clinic in treating older patients with type 2 diabetes for their glycaemic control

Aims. The aim of this study is to determine the effectiveness of a diabetes nurse clinic intervention in controlling the poor glycaemia of older patients with type 2 diabetes. Research method. This is a quasi‐experimental design with pre‐ and follow‐up tests. The study was conducted in a regional acute hospital in Hong Kong. A total of 150 (75 controls, 75 cases) poor glycaemic control older patients with diabetes were recruited in the study. Outcome measures. Biomedical and psychological data were collected at pre‐ and follow‐up period and compared between groups. Results. The study results show an effective intervention of diabetes nurse clinic in giving consultation and education to the type 2 diabetic patients. Subjects in the nurse follow‐up group showed an improvement in the HbA1c, and systolic blood pressure and reduction on healthcare utilization. Conclusion. The study provided evidence to support the diabetes nurse clinic in treating the older patients with diabetes. This study has provided confidence to the diabetes nurse to treat the unstable older patients with diabetes. Relevance to clinical practice. Diabetes mellitus is a serious health concern that most commonly affects older people. As indicated by the results of this study, this educational programme can act as an effective nursing intervention to the type 2 diabetic patients.     

Managing care in the community for patients with type 2 diabetes

Jean Peters and colleagues researched the perceptions of 97 practice nurses and 69 diabetes specialist nurses regarding their current and future role in the management of people with type 2 diabetes in the community. Issues of concern that were identified included patients, resources, training and professional responsibilities.     

Development of a nurse-led chronic pain clinic in UK primary care

We describe the development of an innovative, nurse-led chronic pain clinic in primary care. Benefit of the structured intervention was seen in terms of overall patient pain (as measured by the short form McGill-Melzack pain scale) with no overall impact on drug costs. A significant proportion (54%) of patients taking non-steroidal anti-inflammatory drugs were deemed to be at risk of gastropathy and in need of gastroprotection as defined by the clinic protocol. Areas worthy of further study are discussed.     

Survival of unselected stroke patients in a stroke unit compared with conventional care

BACKGROUND: Recent meta-analyses have reported a beneficial effect of stroke units compared with traditional care, both on patient survival and on dependency after one year. AIM: To determine whether these results can be reproduced outside a clinical trial setting. SETTING: A medium-sized general hospital. METHODS: From 1993 to 1998, all patients aged >60 years with suspected acute stroke were allocated either to a stroke unit or general medical wards according to date of birth (day of the month). Patients were identified retrospectively, using a discharge diagnosis of ICD-9 codes 431, 434 and 436. We assessed 30-day and 1-year survival. RESULTS: In the stroke unit, 926/1128 patients survived at 30 days, vs. 905/1141 in the general medical wards (p=0.08). Beyond the first 30 days, there was no difference in survival (p=0.27). Under Cox regression analysis, there was a 20% reduction in mortality in the stroke unit after 30 days compared with the general medical wards (RR 0.80, p=0.02) after adjusting for age, gender, stroke type and season of the year. DISCUSSION: In this, the largest single-centre study to evaluate the survival benefit of a stroke unit, survival at 30 days was increased, although not significantly so. Survival at one year was unchanged.     

Prevalence of diabetes complications in adolescents with type 2 compared with type 1 diabetes

OBJECTIVE: To compare the prevalence of diabetes complications and their risk factors in youth with type 1 versus type 2 diabetes. RESEARCH DESIGN AND METHODS: We performed a comparative clinic-based study of 1,433 patients with type 1 diabetes and 68 patients with type 2 diabetes aged <18 years from New South Wales, Australia. Retinopathy was assessed by seven-field stereoscopic retinal photography; albumin excretion rate from three consecutive, timed, overnight urine collections; peripheral neuropathy by thermal and vibration threshold; and autonomic neuropathy by pupillometry. HbA(1c) (A1C) and lipids were measured in all patients and C-peptide in patients with type 2 diabetes. RESULTS: In patients with type 1 versus type 2 diabetes, median (interquartile range) age was 15.7 years (13.9-17.0) and 15.3 years (13.6-16.4), respectively (P = 0.2), whereas median diabetes duration was 6.8 years (4.7-9.6) and 1.3 years (0.6-3.1), respectively (P < 0.0001). Retinopathy was significantly more common in patients with type 1 diabetes (20 vs. 4%, P = 0.04), while microalbuminuria and hypertension were significantly less common (6 and 16% in type 1 diabetes vs. 28 and 36% in type 2 diabetes). Rates of peripheral and autonomic neuropathy were similar (27 and 61% in type 1 diabetes vs. 21 and 57% in type 2 diabetes). In multivariate analyses, microalbuminuria was significantly associated with older age (odds ratio 1.3 [95% CI 1.2-1.5], P < 0.001) and systolic hypertension (3.63 [2.0-6.3], P < 0.001) in type 1 diabetes, while only higher A1C (1.7 [1.3-2.9], P = 0.002) was significant in patients with type 2 diabetes. CONCLUSIONS: Youth with type 2 diabetes have significantly higher rates of microalbuminuria and hypertension than their peers with type 1 diabetes, despite shorter diabetes duration and lower A1C. The results of this study support recommendations for early complications screening and aggressive targeting of glycemic control in patients with type 2 diabetes.     

Cerebral perfusion in patients with arterial hypertension associated with type 2 diabetes

The aim of the study was to assess cerebral perfusion (CP) in patients with arterial hypertension in combination with type II diabetes. The subjects were 57 patients with stage II AH (mean age 51.6 +/- 5.7 years), among who there were 33 patients without disturbances in carbohydrate exchange and 24 patients with compensated or subcompensated type II diabetes. All the patients underwent single-photon emission computed tomography of the brain with 99m Tchexamethylpropyleneamineoxime. The study showed that patients suffering from AH with or without type II diabetes had signs of cerebral hypoperfusion and lowered cerebrovascular reserve even in the absence of focal neurological symptoms. Disturbances in cerebral perfusion were more prominent in patients suffering from AH with type II diabetes vs. patients without carbohydrate exchange disorder.     

Survival in patients with type 2 diabetes in a Swedish community: skaraborg hypertension and diabetes project

OBJECTIVE: To explore risk factors for all-cause mortality in patients with type 2 diabetes treated in primary care. RESEARCH DESIGN AND METHODS:A prospective population-based study of 400 patients with type 2 diabetes who consecutively completed an annual checkup in primary care in Skara, Sweden, during 1992-1993. Vital status was ascertained to year 2000. Baseline characteristics as predictors for mortality were analyzed by Cox regression and expressed as relative risks (RRs), with 95% CIs. RESULTS: During a mean follow-up time of 5.9 years, 131 patients died (56 deaths per 1,000 patients per year). In both sexes, all-cause mortality was predicted by HbA(1c) (by 1%; RR 1.14, 95% CI 1.01-1.27), and by LDL-to-HDL cholesterol ratios (1.15, 1.00-1.32). Increased mortality was also seen with prevalent hypertension (1.72, 1.21-2.44), microalbuminuria (1.87, 1.27-2.76), and previous cardiovascular disease (1.70, 1.15-2.50). Subanalyses revealed that increased mortality related to HbA(1c) was restricted to hypertensive patients with type 2 diabetes (1.23, 1.04-1.47). Serum triglycerides (by 1 mmol/l) predicted all-cause mortality in women (1.25, 1.06-1.47). CONCLUSIONS: Poor glucose and lipid control and hypertension predicted all-cause mortality. Survival was also predicted by prevalent microalbuminuria and by previous cardiovascular disease. Confirming results from clinical trials, this population-based study has implications for primary and secondary prevention.     

Team clinic: Expansion of a multidisciplinary care model for adolescents with type 1 diabetes

BackgroundAdolescent and young adults (AYA) with Type 1 Diabetes (T1D) experience more difficulty with glycemic control than patients in all other age groups. The shared medical appointment (SMA) model has been effective in multiple healthcare populations, but the feasibility and effectiveness of SMA in AYA patients with T1D is unclear.MethodsThis research leverages the team's multidisciplinary expertise to develop an engaging intervention toolkit and test the implementation of the Team Clinic care model for the treatment of T1D among middle school adolescents in a large urban children's hospital serving an economically, racially and ethnically diverse population. In Phase 1, the team will manualize the Team Clinic care model into an engaging, age-appropriate educational and intervention toolkit. In Phase 2, the team will conduct a randomized clinical trial to test the feasibility and usability of the toolkit from the provider perspective (team member satisfaction; clinical efficiency; compliance with American Diabetes Association, American Association of Diabetes Educators, and California Children's Services standards; and payor-level cost data) and the preliminary efficacy of the intervention toolkit on patient- and family-level outcomes (attendance, acceptability/satisfaction with care, patient-level cost data, diabetes outcomes, diabetes family conflict, diabetes distress, and depression).DiscussionAYA patients with T1D often receive care in clinics and institutions with limited resources and time. This research tests the feasibility and efficacy of an innovative and potentially cost-effective SMA model to address the unique needs of underserved populations, while meeting national and state clinical standards.Trial registrationThe study is registered with ClinicalTrials.gov (Protocol Record: NCT04190368).     

Treatment gaps for hypertension management in rural Canadian patients with type 2 diabetes mellitus

BACKGROUND: There were a reported 2.2 million Canadians living with diabetes mellitus (DM) in 2002, of whom 1.98 million (90.0%) had type 2 DM. In addition, there are approximately 60,000 new cases of type 2 DM diagnosed in Canada each year. However, the research shows that evidence and guidelines for management of hypertension in DM are not always translated into clinical practice. In rural areas, factors affecting implementation of recommendations and/or guidelines are less well understood, although some studies suggest that urban practices provide higher quality of care overall than rural areas. OBJECTIVE: The goal of this study was to describe the patterns of medication use for hypertension for patients with type 2 DM in rural northern Alberta, Canada. We also tried to identify treatment gaps and opportunities for prescribing antihypertensives relative to the Canadian Diabetes Association's 1998 Clinical Practice Guidelines for the Management of Diabetes in Canada and the Canadian Hypertension Society Recommendations Working Group's 2003 Canadian Recommendations for the Management of Hypertension: Therapy. METHODS: This study was conducted at the Institute of Health Economics and the University of Alberta (Edmonton, Alberta, Canada). We collected information from a cohort of patients aged >or =20 years with type 2 DM living in 2 adjacent rural regions of northern Alberta, Canada, at the time of enrollment in a diabetes care quality-improvement program as part of the Diabetes Outreach Van Enhancement (DOVE) study. Treatment gaps were determined by comparing antihypertensive pharmacotherapy with a blood pressure (BP) target of < or =130/< or =85 mm Hg. We used multivariate regression analyses to determine the associations between sociodemographic and clinical characteristics and treatment gaps. RESULTS: A total of 392 patients (229 women, 164 men; mean [SD] age, 62.3 [12.5] years) with type 2 DM were included in this analysis. Patients had a mean (SD) duration of diabetes of 8.3 (8.5) years. A total of 75.8% (297/392) of the study population had hypertension, and most (236/392[60.2%]) were receiving some pharmacotherapy. Treatment gaps were present; 42.7% (n = 67) of patients not receiving pharmacotherapy for hypertension were above the established BP targets. For patients receiving monotherapy, 70% were not at BP targets. For patients receiving dual, triple, and > or =4 medications, 65%, 66%, and 46%, respectively, were not at BP targets. After controlling for systolic blood pressure, male sex (adjusted odds ratio [aOR], 2.17; 95% CI, 1.17-4.03), older age (aOR, 1.80 per decade; 95% CI, 1.51-2.09), lower self-reported physical health (aOR, 0.68; 95% CI, 0.41-0.96), higher body mass index (aOR, 1.05; 95% CI, 1.01-1.10), and past/current smoking (aOR, 1.95; 95% CI, 1.01-3.76) were all significantly associated with a lack of treatment for hypertension. CONCLUSIONS: Treatment maps in the management of hypertension exist in these rural Canadian patients with type 2 DM. Cardiovascular risk may be underestimated in these patients, particularly among younger patients and women, and those with multiple non-DM risk factors. These are patient subgroups that should be targeted as opportunities to improve hypertension management at the population level.     

Setting up a fast-track insulin start clinic for type 2 diabetes

When people with established type 2 diabetes first need insulin therapy there is often a delay in accessing services. Since the report of the UK Prospective Diabetes Study was published it has been recognised that people with type 2 diabetes have a progressive disease and a need for increasing treatment. The authors set up a fast-track service to enable GPs and practice nurses to refer to a nurse-led service at the diabetes centre.     

Medical costs of managed care in patients with type 2 diabetes mellitus

The main objective of this study was to analyze the principal treatment cost drivers in patients with type 2 diabetes mellitus in a managed care setting. The study used retrospective integrated (linked) medical and pharmacy claims data for the calendar year 1995. The data were obtained from, and in cooperation with, the Hawaii Medical Service Association, Honolulu, Hawaii. The medical claims data included paid claims for services and procedures for diabetes and commonly associated comorbidities. Claims and associated costs for pharmacotherapy administered to the patient population were recorded in the pharmacy data. Patients aged > or =65 years were excluded because Medicare claims were unavailable for the type 2 diabetic population. The sample used in this study included 5171 patients. An ordinary least squares regression model was employed to identify principal cost drivers among the identified cohort to the managed care system. Independent variables in the analysis consisted of the presence or absence of a number of commonly observed comorbidities associated with diabetes mellitus (hypertension, hyperlipidemia, cardiovascular diseases, congestive heart failure, renal disorders, retinopathy, neurologic disorders, and any cardiac or noncardiac comorbidity combinations), pharmacologic therapy variables (insulin, oral medication, or both), a number of significant events (hospitalization, dialysis, hemoglobin A1c testing, and eye examination), patient enrollment category (fee-for-service vs a capitated system), and patient age and sex. The dependent variable was the natural logarithm of total medical costs of treatment for diabetes and commonly observed comorbidities. Results showed that among comorbidity variables, the 3 largest treatment cost drivers for patients with type 2 diabetes were the presence of neurologic disorders, renal disorders, and any comorbidity combination (cardiac or noncardiac or both), in decreasing order of significance. Similarly, higher costs of treatment were associated with episodes of hospitalization, use of antidiabetic medication, dialysis services, and hemoglobin A1c testing. Whether the patient was being treated under a capitated provider payment system or a fee-for-service system did not have any significant impact on the medical costs of diabetes-related treatment. Age was positively associated with these costs, indicating that older patients were more likely to incur higher costs to the system. The overall explanatory power of the model was 40%. In summary, unless diabetes is properly managed and glucose levels monitored, some component of an integrated health system (hospital vs pharmacy) necessarily bears financial risk. An understanding of the underlying cost distribution for a chronic disease could help in targeting interventions, integrating disease-management services, and managing the formal structure of the health plan being considered.     

2型糖尿病合并高血压缺血修饰清蛋白的变化

目的：探讨缺血修饰清蛋白（IM A ）与2型糖尿病合并高血压的关系及其临床意义。方法选取2012年3～5月于第三军医大学第三附属医院体检的健康体检者150例为对照组,高血压内分泌科确诊的2型糖尿病合并高血压住院患者150例为实验组,用间接清蛋白钴结合试验（ACB法）测定两组血清IM A水平并进行比较分析。结果实验组患者血清IMA水平明显高于对照组,差异有统计学意义（P＜0．05）;且女性患者明显高于男性,35～50岁年龄组患者明显高于66～81岁年龄组,差异均有统计学意义（ P＜0．05）。结论 IM A检测对2型糖尿病合并高血压疾病具有早期监测和预防意义。     

协同护理模式在2型糖尿病患者中的应用研究

目的评价协同护理模式对2型糖尿病患者生活质量、空腹血糖、餐后2 h血糖、糖化血红蛋白、低血糖发生率及胰岛素规范注射技术的影响。方法将240例胰岛素治疗的2型糖尿病患者随机分为观察组和对照组各120例,对照组采取常规护理,观察组在常规护理基础上采取协同护理模式:包括重点指导患者正确掌握胰岛素规范注射9步骤方法、注射角度及手法、常用注射部位的轮换及消毒、注射针头一次性使用、注射完毕停留的时间及胰岛素的正确保存方法等。比较两组患者出院3个月后的生活质量和空腹血糖、餐后2 h血糖、糖化血红蛋白、低血糖发生率及胰岛素规范注射技术。结果应用协同护理模式干预后,观察组患者生活质量评分高于对照组(P0.01),空腹血糖、餐后2 h血糖、糖化血红蛋白、低血糖发生率明显低于对照组(P0.01或P0.05),胰岛素规范注射技术高于对照组(P0.01)。结论协同护理模式应用于2型糖尿患者,可提高患者的生活质量,有效控制血糖及糖化血红蛋白,降低低血糖发生率,规范患者胰岛素注射技术。     

General practitioners' perceptions of a community-based nurse-led assessment clinic for patients with benign prostatic hyperplasia

The prevalence of benign prostatic hyperplasia (BPH) increases with age; therefore, this condition is likely to rise as people live longer. This poses challenges in how best health services can be organized to diagnose, treat or manage this disease effectively. A community‐based nurse‐led clinic was set up to assess and advice people with BPH who were referred by general practitioners (GPs). The aim of this study was to explore the perceptions of GPs of the value and benefits of the nurse‐led BPH clinic. Two focus groups were carried out with a random sample of 10 GPs (five in each group). The findings showed that the assessment carried out at the clinic by the specialist nurse helped them to avoid the ‘trial and error’ approach that GPs sometimes used in treating this condition. Although they did not find that the clinic reduced their (GPs) workload, it offered a valuable, enhanced service to help them make accurate diagnosis and prescribe appropriately, thereby contributing to the quality of life of patients. This study showed that nurses’ and doctors’ work can complement each other to the benefit of patients. It adds to the growing evidence that appropriate skill mix can contribute to effective practice.