Role of diabetologists in the management of nonalcoholic fatty liver disease: Primary prevention and screening/management of fibrosis and cirrhosis

Background and aimsNonalcoholic fatty liver disease (NAFLD) is a common condition, especially among individuals with type 2 diabetes (T2D). Presence of T2D increases the risk of progression of simple steatosis to more severe liver conditions, such as nonalcoholic steatohepatitis (NASH) and fibrosis (NASH-fibrosis). Since majority of patients with T2D are managed by diabetologists (including physicians and endocrinologists), their roles in the management of coexisting NAFLD are not well defined, partly due to lack of unambiguous guidelines.MethodsA literature search was performed with Medline (PubMed), Scopus and Google Scholar electronic databases till January 2022, using relevant keywords (nonalcoholic fatty liver disease and diabetologist; screening of NASH; management of NASH) to extract relevant studies describing prevention and screening of NAFLD/NASH, especially in people with T2D.ResultsDiabetologists have two main roles for the management of patients with T2D and coexisting NAFLD. The most important role is to prevent the development of NASH-fibrosis in patients with simple steatosis (primary prevention). This can be achieved by reinforcing the importance of lifestyle measures, and by early use of glucose-lowering agents with beneficial effects on the liver. The second important role of diabetologists is to screen all patients with T2D for liver fibrosis and compensated cirrhosis, and provide appropriate referral for timely management of complications (secondary prevention).ConclusionDiabetologists can play a central role in mitigating the epidemic of NAFLD in individuals with T2D. However, diabetologists need to be aware about their roles in NASH-fibrosis prevention and screening. Furthermore, longitudinal studies should explore the role of newer glucose-lowering drugs in the primary prevention of NASH-fibrosis in individuals with coexisting T2D and simple steatosis.     

Optimal care of cardiovascular disease and type 2 diabetes patients: shared responsibilities between the cardiologist and diabetologist

Type 2 diabetes and cardiovascular disease are inextricably linked. Patients with type 2 diabetes are at increased risk of cardiovascular events and mortality. However, controlling blood glucose, which until recently had often been the focus of the diabetologist, is only one component of optimal cardiovascular risk reduction. Vascular protection of the patient with diabetes also includes management of hypertension and dyslipidaemia and lifestyle changes such as smoking cessation. Now both cardiologists and diabetologists need to optimise all components of vascular protection, including glycaemic control, in patients with diabetes. An elevated blood glucose is predictive of poor outcomes in patients with acute coronary syndromes, even if frank diabetes is not present. Early control of hyperglycaemia should be achieved: a strategy that results in improved outcomes. More than two-thirds of patients with coronary artery disease (CAD) have abnormal glucose regulation, which is a predictor of poor outcome. Therefore, the presence of diabetes (and/or glucose intolerance) should be routinely screened for in cardiac patients on admission to hospital. Early identification and treatment of CAD in patients with diabetes is important for optimal prevention of cardiovascular events. However, screening all diabetes patients for CAD is not feasible, and selection of patients for non-invasive cardiac testing remains a challenge for both the diabetologist and cardiologist. Optimal care of diabetic and cardiac patients requires a multidisciplinary team approach, with key roles for the cardiologist and diabetologist.     

Prediabetes awareness among Southeastern European physicians

Aims/Introduction

Prediabetes (PD) represents a transitional state where the glucose levels are higher than normal, but not enough for diabetes mellitus diagnosis. As there is a growing number of the population with PD, its early detection and treatment could prevent the development of diabetes mellitus and its complications. We aimed to assess the overall knowledge of PD among medical professionals of different varieties.

Materials and Methods

A questionnaire‐based study addressing PD and type 2 diabetes mellitus knowledge among Southeastern European general practitioners, postgraduates, physicians and superior specialists was carried out.

Results

A total of 397 physicians completed the questionnaire. The total rate of correct answers from diabetologists, non‐diabetologist internists, residents and general practitioners was 69, 56.1, 54 and 53%, respectively. Questions related to the PD definition achieved a total of 46.6% correct answers. Correct responses considering the numerical definition of impaired fasting glucose and impaired glucose tolerance were 46.3 and 46.8%, respectively. Younger physicians had better knowledge of numerical values regarding PD and type 2 diabetes mellitus criteria (P < 0.001).

Conclusions

The present results show that overall knowledge of PD is poor among Southeastern European physicians, which necessitates adequate educational programs on PD in this region.     

A review of the job satisfaction and current practice of consultant diabetologists in England--barriers and successes.

AIMS: The project aimed to describe the perceptions of consultant diabetologists about their work, explore models of care, identify problem areas, consider potential solutions, and outline strategic issues for retention and recruitment. METHODS: The study was based on semistructured qualitative interviews with 92 consultant diabetologists, recruited via a purposive sample. Interviews were recorded, transcribed and anonymized, and analysed by the project team, assisted by QSR Nvivo software. RESULTS: The consultant diabetologist role encompasses a diversity of skills/expertise, with differing emphases between individuals. Integration with general medicine is seen by some as crucial to maintaining proficiency in diabetes, and by others as hindering fulfilment of other roles. Successful team working across organizational boundaries is recognized as essential to effective services, but often impeded by the continuous reorganization and competitive culture of the National Health Service. Significant differences between consultant diabetologist perspectives of primary care colleagues and of primary care trusts emerged. Some consultants have adopted innovative working approaches, adapting national guidance to local environments, but there is general resistance to adopting centrally imposed solutions. Training programmes are not sufficiently explicit about the core skills/attributes required of consultant diabetologists. CONCLUSIONS: The skills of specialist teams are not fully exploited. Competing calls on time could be addressed by encouraging multifaceted consultant teams, allowing individuals to concentrate in specific areas. Clear definition of core skills required by consultant diabetologists underpins training programme development. Collaboration in cross-boundary services reflecting local needs is impeded by competition between sectors. Protected time is necessary for cultivating multidisciplinary teams, cross-boundary partnerships and effective, relevant education programmes. Specialist training must reflect the changing role of consultant diabetologists, and include role-specific programmes.     

Quality of cardiovascular disease preventive care and physician/practice characteristics

BACKGROUND: Quality of cardiovascular disease (CVD) preventive care is suboptimal. Recent data correlated increasing years in practice for physicians with lower-quality health care. OBJECTIVE: The purpose of this study was to assess physician awareness/adherence to national blood pressure, cholesterol, and CVD prevention guidelines for women according to physician/practice characteristics. DESIGN: Standardized online survey and experimental case studies were administered to 500 randomly selected U.S. physicians. Multivariable regression models tested physician age, gender, specialty, and practice type as independent predictors of guideline awareness/adherence. RESULTS: Compared with older physicians (50+ years), younger physicians (<50 years) reported a lower level of awareness of cholesterol guidelines (P=.04) and lower incorporation of women's guidelines (P=.02). Yet, older physicians were less likely to recommend weight management for high-risk cases (P=.03) and less confident in helping patients manage weight (P=.045) than younger physicians. Older physicians were also less likely to identify a low-density lipoprotein<100 mg/dL as optimal versus younger physicians (P=.01), as were solo versus nonsolo practitioners (P=.02). Solo practitioners were less aware of cholesterol guidelines (P=.04) and were more likely to prescribe aspirin for low-risk female patients than nonsolo practitioners (P<.01). Solo practitioners rated their clinical judgment as more effective than guidelines in improving patient health outcomes (P<.01) and more frequently rated the patient as the greatest barrier to CVD prevention versus nonsolo practitioners (P<.01). CONCLUSIONS: Though guideline awareness is high, efforts to promote their utilization are needed and may improve quality outcomes. Targeted education and support for CVD prevention may be helpful to older and solo physicians.     

Non-compliance to practice guidelines still exist in the early management of acute pancreatitis: Time for reappraisal?

IntroductionEarlier national surveys on the management of acute pancreatitis (AP) had reported non-compliance to practice guidelines. In the past decade, several guidelines were revised based on new evidence. In this multicenter international survey, we aimed to evaluate the practice patterns of early management of AP and compliance to the revised treatment guidelines across different disciplines and practice environments.MethodsA structured questionnaire was sent via email to a target population of 654 that constituted of medical and surgical gastroenterologists, physicians and general surgeons, paediatricians from academic and non-academic centres across 30 countries. Other than demographic variables, the questionnaire contained items pertaining to early management of AP, such as, assessment at admissions and within first 72 h s, details regarding analgesics, IV hydration, oral/enteral feeding and antibiotic use.ResultsThe response rate was 46.2% and after exclusions, a total of 297 participant's responses were analysed. Majority of the participants were from Asia, followed by Europe and the Americas. 181 (60.9%) claimed to follow practice guidelines, out of which 59 (32.6%) followed more than one. On further probing, only 41.9% were actually compliant to feeding and 59.7% to antibiotic guidelines. Even though participants opted for aggressive hydration, early feeding and avoidance of prophylactic antibiotics, there were non-compliance and discrepancies in titration of fluid therapy, indications of feeding and antibiotic use.DiscussionDiscrepancies and non-compliance still appear to exist in the early management of AP due to lack of strong evidence. We discuss ways that could improve compliance to the existing guidelines until stronger evidence comes to the fore.     

Screening,evaluation and management of depression in people with diabetes in primary care

Family physicians are responsible for diagnosing and treating the majority of people with type 2 diabetes mellitus and co-morbid depression. As a result of the impact of co-morbid depression on patient self-care and treatment outcomes, screening for depression in the context of a structured approach to case management and patient follow up is recommended in people with diabetes and cardiovascular disease. This review summarizes the need for improved recognition and treatment of depression in diabetes; and makes expert recommendations with regard to integrating screening tools and therapies into a busy family or general medical practice setting.     

Attitudes and practices of resident physicians regarding hypertension in the inpatient setting

Hypertension is prevalent in the population at large and among hospitalized patients. Little has been reported regarding the attitudes and patterns of care of physicians managing nonemergent elevated blood pressure (BP) among inpatients. Resident physicians in internal medicine (IM), family medicine (FM), and surgery were surveyed regarding inpatient BP management. One hundred eighty-one questionnaires were completed across 3 sites. Respondents generally considered inpatient BP control a high priority. A majority of IM and FM residents indicated following the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) consensus guidelines for inpatients compared to 20% of surgery residents (P<.001). While trainees did not appear to strictly follow JNC 7 guidelines for goal BP of 140/90 mm Hg, they did report making frequent BP medication changes (～51% reported changing regimens for >50% of hypertensive patients). Overall ～90% indicated that discharging a hypertensive patient on a drug regimen established during hospitalization is preferable to reverting to the regimen in place at the time of admission. Resident physicians regard elevated BP inpatient management as important, but attitudes and practice vary between specialties. JNC 7 guidelines may not be appropriate for inpatient use. Future research should focus on developing functional diagnostic criteria for hypertension in the inpatient setting and determining best practices inpatient BP management.     

Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy

Guidelines on the out-patient management of diabetic peripheral neuropathy have been developed from an international consensus meeting attended by diabetologists, neurologists, primary care physicians, podiatrists and diabetes specialist nurses. A copy of the full document follows this summary (Appendix 1). The document arose out of suggestions from Neurodiab, a subgroup of the European Association for the Study of Diabetes, that there was a need for guidelines developed by consensus, for the outpatient management of patients with diabetic neuropathy. An international consensus group was created, chaired by two of the authors. A pilot working party met in 1995, followed by a full working party of 39 experts, neurologists and diabetes physicians (Appendix 2). This compiled a draft guideline document which was circulated to a number of international bodies. After consultation with its members, the final guidelines were approved by Neurodiab (chairman F.A. Gries) towards the end of 1997. © 1998 John Wiley & Sons, Ltd.     

Glycaemic management during the inpatient enteral feeding of people with stroke and diabetes

This paper is an abridged and modified version of guidelines produced by the Joint British Diabetes Societies for inpatient care on glycaemic management during the enteral feeding of people with stroke and diabetes. These were revised in 2017 and have been adapted specifically for Diabetic Medicine. The full version can be found at: www.diabetes.org.uk/joint-british-diabetes-society or https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group . Many people have both diabetes and an acute stroke, and a stanv dard approach to the management of people with stroke is the provision of adequate nutrition. Frequently, this involves a period of enteral feeding if there is impaired ability to swallow food safely. There is currently considerable variability in the management of people with diabetes fed enterally after a stroke, and the evidence base guiding diabetes management in this clinical situation is very weak, although poor glycaemic outcomes in people receiving enteral feeding after stroke may worsen recovery and cause harm. The aim of this document is to provide sensible clinical guidance in this area, written by a multidisciplinary team; this guideline had input from diabetes specialist nurses, diabetologists, dietitians, stroke physicians and pharmacists with expertise in this area, and from UK professional organizations. It is aimed at multidisciplinary teams managing people with stroke and diabetes who require enteral feeding. We recognize that there is limited clinical evidence in this area.     

Correlates of satisfaction for the relationship with their physician in type 2 diabetic patients

In the context of an Italian nation-wide outcomes research program on type 2 diabetes, we investigated the contribution of both patient and setting-related factors to patient satisfaction with their relationship with their physicians. The level of patient satisfaction was measured using the American Board of Internal Medicine (ABIM) 14 patient satisfaction questionnaire. The main results were obtained using multilevel analysis, a statistical technique that takes into account the clustered nature of our data. Overall, 3563 patients were recruited by 101 diabetologists and 103 general practitioners (GPs). Information on patients' satisfaction was available for 2515 patients (71% of the whole sample). Patients' satisfaction was related to patient characteristics and attitudes, but not with physician's sex, age, speciality, and setting of care. In particular, patients who were less likely to delegate to physicians responsibility for diabetes management and those perceiving a lower degree of involvement in disease management showed lower levels of satisfaction. Lower satisfaction scores were also related to lower levels of school education, more severe clinical conditions, and lower psychological adaptation to diabetes. However, patients reporting higher levels of diabetes related worries and more frequent encounters with health care providers showed higher levels of satisfaction. In conclusion, patient satisfaction with physicians' humanness and communication skills is strongly related to personal characteristics, attitudes, expectations, and perceived health. In deciding the best decision-making approach to adopt in individual patients, it is of primary importance to measure how the patient perceives and engages in relationships.     

Physician gender is associated with the quality of type 2 diabetes care

Objectives. Patient gender influences the quality of medical care whilst the role of physician gender is not well established. To investigate the influence of physician gender on quality of care in patients with type 2 diabetes. Design and methods. Cross‐sectional study in 51 053 outpatients (48.6% male), treated by 3096 office‐based physicians (66.3% male; 74.0% general practitioners, 21.8% internists and 4.2% diabetologists). Outcome measures included processes of care, intermediate outcomes and medical management. Quality of care measures were based on current ADA guidelines. Hierarchical regression models were used to avoid case‐mix bias and to correct for physician‐level clustering. Adjusted odds ratios were calculated controlling for age, gender, disease duration and presence of atherosclerotic disease. Results. The patients of female physicians were more often women, more obese, older and had more often atherosclerotic disease (34% in the total cohort). The patients of female physicians more often reached target values in glycaemic control (HbA1c < 6.5%; OR 1.14; 1.05–1.24, P = 0.002), blood lipoproteins (LDL‐C < 100 mg dL⁻¹; OR 1.16; 1.06–1.27, P = 0.002), and blood pressure (systolic values < 130 mmHg; OR 1.11; 1.02–1.22, P = 0.018). They were more likely to receive antihypertensive drug therapy in general (OR 1.35; 1.24–1.46, P < 0.0001) and angiotensin converting enzyme (ACE) inhibitors in particular (OR 1.17; 1.09–1.25, P < 0.0001). The patients of female physicians less often performed glucose self‐monitoring (OR 0.83; 0.76–0.91, P < 0.0001) and less often received oral hypoglycaemic agents (OR 0.88; 0.82–0.95, P = 0.001). Conclusions. Physician gender influences quality of care in patients with type 2 diabetes. Female physicians provide an overall better quality of care, especially in prognostically important risk management.     

Physician experts in diabetes are natural team leaders for managing diabetic patients with foot complications. A position statement from the Italian diabetic foot study group

Diabetic foot syndrome (DFS) is a complex disease. The best outcomes are reported with the multi-disciplinary team (MDT) approach, where each member works collaboratively according to his/her expertise. However, which health provider should act as the team leader (TL) has not been determined.The TL should be familiar with the management of diabetes, related complications and comorbidities. He/she should be able to diagnose and manage foot infections, including prompt surgical treatment of local lesions, such as abscesses or phlegmons, in an emergent way in the first meeting with the patient.According to the Organization for Economic Co-operation and Development (OECD) reports, Italy is one of countries with a low amputation rate in diabetic patients. Many factors might have contributed to this result, including 1)the special attention directed to diabetes by the public health system, which has defined diabetes as a “protected disease”, and accordingly, offers diabetic patients, at no charge, the best specialist care, including specific devices, and 2)the presence of a network of diabetic foot (DF) clinics managed by diabetologists with medical and surgical expertise. The health care providers all share a “patient centred model” of care, for which they use their internal medicine background and skills in podiatric surgery to manage acute or chronic needs in a timely manner.Therefore, according to Italian experiences, which are fully reported in this document, we believe that only a skilled diabetologist/endocrinologist should act as a TL. Courses and university master's degree programmes focused on DF should guarantee specific training for physicians to become a TL.     

Cardiovascular risk stratification in general practice

CONCLUSION: The ESC risk charts are helpful to identify high risk patients in general practice who are candidates for preventive treatment. The use of the ESC charts is one important step to initiate "evidence based medicine" in the daily practice of preventive cardiology.Cardiovascular diseases are the most important causes of premature disability and death in Germany. High risk patients however are frequently not recognized. A systematic risk stratification in general practice could identify high risk persons and allow a cost effective treatment approach. The goal of the CAD-scoring week was to identify high risk persons with the use of the ESC risk charts and to evaluate the treatment resulting from risk stratification. In addition the feasibility of the risk charts in daily office routine was to be evaluated. A total of 1122 of 20 000 (5.6%) contacted general physicians agreed to participate in the screening procedure. More than 27 000 patients (> 50 yrs) were evaluated using the ESC risk charts. 21.6% of women (n = 15 018) vs 22.2%* of men (n = 12 361) had markedly elevated blood pressure (> 150 mmHg), 29 vs. 24%* had a total cholesterol > 250 mg/dl (6.5 mmol/l), 25.5 vs 29.9%* smoked and 28.4 vs. 31.9%* had diabetes (*female vs male: p < 0.0003). Altogether 19.4% of women vs. 53% of men were newly identified as high risk patients (risk > 20% in 10 years). More than 40% of these high risk patients received drug treatment for prevention (ASA, lipid lowering drugs or ACE inhibitors). More than 70% of the participating physicians judged the risk charts to be helpful in patient management.     

Management of High Blood Pressure in Clinical Practice: Perceptible Qualitative Differences in Approaches Utilized by Clinicians

The authors recruited a group of physicians from among the investigators participating in the Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) with a greater (more successful) or lesser (less successful) proportion of trial patients meeting blood pressure (BP) control goals. The authors utilized qualitative focus group methods to identify similarities and differences in practice behaviors. Successful and less successful physicians had similarities in knowledge and practice behaviors regarding awareness of treatment guidelines, approaches to diagnosis, use of pharmacologic management, and the opinion that systolic BP guidelines should consider a patient’s age. However, there were discernible differences between the two physician groups in their views on doctor‐patient relationships: physicians from the less successful group were more paternalistic with their patients, while physicians from the more successful group were more likely to use a patient‐centered clinical approach to BP awareness and management.     

Physician awareness and self-reported use of local and national guidelines for community-acquired pneumonia

OBJECTIVES: To assess physician awareness and reported use of medical guidelines for community-acquired pneumonia (CAP), and to identify factors associated with variations in awareness and use of these guidelines. DESIGN: A questionnaire was administered during the preintervention phase of a randomized clinical trial of a pneumonia guideline implementation strategy. PARTICIPANTS: Three hundred and fifty-two physicians who managed CAP patients at 7 Pittsburgh, PA hospitals completed the questionnaire. Physician and practice setting characteristics, and physician awareness and reported use of national American Thoracic Society (ATS) and local (hospital-developed) guidelines for CAP were assessed. RESULTS: Overall, 48% reported being influenced by ATS guidelines and 20% reported using these guidelines; 48% were uncertain whether a local pneumonia guideline existed. Only 28% of physicians who knew a local guideline existed reported frequently using the guideline. Use of national ATS guidelines was independently associated with practice as an infectious disease or pulmonary medicine specialist, nonpatient care-related professional activities, and intellect personality score. Use of local guidelines was independently negatively associated with practice as an infectious disease or pulmonary medicine specialist, and positively associated with positive attitudes toward practice guidelines. CONCLUSIONS: Results indicate low levels of awareness and use of guidelines for the management of CAP. Key indicators (e.g., medical specialty, fewer clinical duties, and positive attitudes about guidelines) were associated with greater use of national and local guidelines. If replicated with data on actual physician management practices, more effective guideline implementation strategies will be necessary to encourage compliance with practice guidelines for the management of CAP.     

Microalbuminuria Screening in the UK: Are We Meeting European Standards?

European guidelines recommend annual screening for microalbuminuria in patients with Type 1 (insulin-dependent) diabetes mellitus (IDDM) of greater than 5 years' duration and in those with Type 2 (non-insulin-dependent) diabetes mellitus (NIDDM) from diagnosis. To determine the current provision of screening for microalbuminuria we performed a postal survey of all diabetologists in the United Kingdom. Of 556 questionnaires sent, 326 (59 %) were returned (246 adult, 57 paediatric, 3 adolescent clinics) and of these 306 (55 %) were suitable for analysis. Screening programmes have been established by 210 (69 %) diabetologists: 70 of these in the last 2 years. 46 more plan to screen patients with IDDM within 2 years. 155 (92 %) of 169 adult programmes perform annual screening in IDDM, 74 % according to European guidelines (39 % in NIDDM). Other clinics use age, type of diabetes or criteria such as blood pressure to target screening. An albumin/creatinine ratio (52 %) on an early morning urine (56 %) or random (29 %) urine sample is most commonly requested. Financial constraint was the principal reason given in 32 (33 %) of 96 clinics that do not currently screen. Other reasons included implementation of other developments with a higher priority (24 %) and doubts about the medical value of screening (46 %). Assuming respondents are representative of current UK practice, we conclude that microalbuminuria screening is available to patients in many clinics, but is neither universal nor always performed according to European guidelines.