Diabetes Disease Management Research Articles

Imaging Beta-Cell Function in the Pancreas of Non-Human Primates Using a Zinc-Sensitive MRI Contrast Agent.

Non-invasive beta cell function measurements may provide valuable information for improving diabetes diagnostics and disease management as the integrity and function of pancreatic beta cells have been found to be compromised in Type-1 and Type-2 diabetes. Currently, available diabetes assays either lack functional information or spatial identification of beta cells. In this work, we introduce a method to assess the function of beta cells in the non-human primate pancreas non-invasively with MRI using a Gd-based zinc(II) sensor as a contrast agent, Gd-CP027. Additionally, we highlight the role of zinc(II) ions in the paracrine signaling of the endocrine pancreas via serological measurements of insulin and c-peptide. Non-human primates underwent MRI exams with simultaneous blood sampling during a Graded Glucose Infusion (GGI) with Gd-CP027 or with a non-zinc(II) sensitive contrast agent, gadofosveset. Contrast enhancement of the pancreas resulting from co-release of zinc(II) ion with insulin was observed focally when using the zinc(II)-specific agent, Gd-CP027, whereas little enhancement was detected when using gadofosveset. The contrast enhancement detected by Gd-CP027 increased in parallel with an increased dose of infused glucose. Serological measurements of C-peptide and insulin indicate that Gd-CP027, a high affinity zinc(II) contrast agent, potentiates their secretion only as a function of glucose stimulation. Taken in concert, this assay offers the possibility of detecting beta cell function in vivo non-invasively with MRI and underscores the role of zinc(II) in endocrine glucose metabolism.

A qualitative study documenting unmet needs in the management of diabetic kidney disease (DKD) in the primary care setting

BackgroundA majority of diabetic kidney disease (DKD) patients receive medical care in the primary care setting, making it an important opportunity to improve patient management. There is limited evidence evaluating whether primary care physicians (PCPs) are equipped to effectively manage these patients in routine clinical practice. The present study was undertaken to identify gaps in primary care and unmet needs in the diagnosis and monitoring of DKD in type 2 diabetes (T2D) patients among PCPs.MethodsThis was a qualitative analysis based on 30–45-min interviews with PCPs treating T2D patients. PCPs were recruited via email and were board-certified, in practice for more than 3 years, spent most of their time in direct clinical care, and provided care for more than three T2D patients in a week. Descriptive data analysis was conducted to identify and examine themes that were generated by interviews. Two reviewers evaluated interview data to identify themes and developed consensus on the priority themes identified.ResultsA total of 16 PCPs satisfying the inclusion criteria were recruited for qualitative interviews. Although the PCPs recognized kidney disease as an important comorbidity in T2D patients, testing for kidney disease was not consistently top of mind, with 56% reportedly performing kidney function testing in their T2D patients. PCPs most frequently reported using estimated glomerular filtration rate (eGFR) alone to monitor and stage DKD; only 25% PCPs reported testing for albuminuria. Most PCPs incorrectly believed that a majority of DKD patients are diagnosed in early stages. Also, early stages of DKD emerged as ambiguous areas of decision-making, wherein treatments prescribed greatly varied among PCPs. Lastly, early and accurate risk stratification of DKD patients emerged as the most important unmet need; which, if it could be overcome, was consistently identified by PCPs as a key to monitoring, appropriate nephrologist referrals, and intervening to improve outcomes in patients with DKD.ConclusionsOur study highlights important unmet needs in T2D DKD testing, staging, and stratification in the PCP setting that limit effective patient care. Health systems and insurers in the U.S. should prioritize the review and approval of new strategies that can improve DKD staging and risk stratification.

Sodium-glucose transporter inhibition in heart failure: from an unexpected side effect to a novel treatment possibility

Sodium-glucose transporter-2 inhibitors (SGLT2i), originally launched as glucose-lowering drugs, have been studied in large cardiovascular outcome trials to ascertain safety. Surprisingly, these compounds reduced the risk of cardiovascular events (cardiovascular death, non-fatal myocardial and non-fatal stroke) and total mortality. The mechanisms behind this benefit are only partly understood, but a major contributor is the reduction of heart failure hospitalisations, evident already within weeks after the initiation of the SGLT2i.SGLT2 inhibition increases urinary glucose excretion, thereby improving glycaemic control in an insulin-independent manner. Moreover, SGLT2i potentially impact the cardiovascular system both indirectly via weight loss and blood pressure lowering and directly through osmotic diuresis and increased sodium excretion and presumably by improving myocardial energetics.The aim of this review is to summarise evidence from all major outcome trials investigating SGLT2i in patients with diabetes, as well as recent evidence from trials in heart failure patients without glucose perturbations, which pave the way for novel treatment of large groups of patients.The results of these studies have been taken into account in recently issued guidelines for the management of diabetes and cardiovascular disease. An important task for diabetologists, cardiologists and general practitioners is to incorporate them into clinical practice to the benefit of many patients.

Association between diabetes education and diabetes management in an under‐resourced community: A pilot study

Aims : Evaluate the effects of limited resources and access to education on diabetic disease outcomes and management in an under-served community. Place and Duration of Study : Data of diabetic Peruvian Amazon patients was collected during a 4-day health clinic conducted through the Michigan State University College of Osteopathic Medicine's (MSUCOM) Peru Global Outreach Project developed in partnership with local Peruvian doctors of Iquitos, Peru (District of Maynas) in August 2019. Methodology : A community-based cross-sectional study employed a convenience sampling of patients from underserved communities of the Peruvian Amazon. Demographic information, lifestyle habits, disease control, and education were collected through a survey. Clinical data were collected during the examination and from the respective patient's chart. Patients who were mentally disabled or incapacitated were not included. (IRB approval: STUDY00002982). Results from the survey were correlated to clinical data related to diabetes symptoms and sequelae. Data are expressed as Mean±SEM (N=11). Statistical analysis was performed by the Chi-square test and Pearson correlation coefficient (CI95). Results : 64% were women. 91% classified themselves as being in low or very low class and had no high school education. Age 56.9±4.8. 100% of the patients have diabetes (random glucose 303.9±43.7mg/dL). 18% were insulin-dependent. 36% were using only metformin. 46% were not using medication to treat diabetes. BMI: 22.5±1.5. Blood pressure: 119±5.8/73.4±2.9mmHg. No correlation (P>.05) was observed between blood pressure, BMI, and age vs. random glucose levels. 100% of the patients wished they had received more education regarding their diabetes diagnosis. 72.7% report visiting their primary care physician. Conclusion The lack of control of glucose levels in patients, despite a majority of patients having a primary care provider as well as receiving treatment, demonstrates the poor quality of understanding and management of the disease by the patients. It was not possible to establish a relationship between diabetes sequelae and random blood glucose levels. However, all subjects desired to receive more education in order to better understand and manage their disease. This pilot study demonstrated the shortcomings of healthcare for people with diabetes in the Peruvian Amazon and the educational barrier that should be addressed to improve disease management and patient outcomes.

Diabetes Patient Surveillance in the Emergency Department: Proof of Concept and Opportunities.

IntroductionThe purpose of this study was to characterize the at-risk diabetes and prediabetes patient population visiting emergency department (ED) and urgent care (UC) centers in upstate South Carolina.MethodsWe conducted this retrospective study at the largest non-profit healthcare system in South Carolina, using electronic health record (EHR) data of patients who had an ED or UC visit between February 2, 2016–July 31, 2018. Key variables including International Classification of Diseases, 10th Revision codes, laboratory test results, family history, medication, and demographic characteristics were used to classify the patients as healthy, having prediabetes, having diabetes, being at-risk for prediabetes, or being at-risk for diabetes. Patients who were known to have diabetes were classified further as having controlled diabetes, management challenged, or uncontrolled diabetes. Population analysis was stratified by the patient’s annual number of ED/UC visits.ResultsThe risk stratification revealed 4.58% unique patients with unrecognized diabetes and 10.34% of the known patients with diabetes considered to be suboptimally controlled. Patients identified as diabetes management challenged had more ED/UC visits. Of note, 33.95% of the patients had unrecognized prediabetes/diabetes risk factors identified during their ED/UC with 87.95% having some form of healthcare insurance.ConclusionThis study supports the idea that a single ED/UC unscheduled visit can identify individuals with unrecognized diabetes and an at-risk prediabetes population using EHR data. A patient’s ED/UC visit, regardless of their primary reason for seeking care, may be an opportunity to provide early identification and diabetes disease management enrollment to augment the medical care of our community.

Glomerular Diseases in Diabetic Patients: Implications for Diagnosis and Management.

The prevalence of diabetes continues to rise worldwide. In addition to rising rates of diabetic kidney disease, we are also seeing a parallel rise in nondiabetic kidney disease among patients with diabetes. These nondiabetic lesions include focal segmental glomerulosclerosis, IgA nephropathy, membranous nephropathy, and other glomerular diseases. The management of diabetic kidney disease is rapidly evolving to include, beyond glycemic control and renin angiotensin inhibition, the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and mineralocorticoid receptor antagonists. These and other new treatment strategies should be applicable to managing glomerular disease in diabetic patients to reduce toxicities associated with immunosuppression and, in particular, corticosteroids. The prevalence of glomerular disease in diabetic patients is underappreciated. Diagnosis and appropriately treating these diseases remain an important avenue to modify kidney outcomes in diabetic patients.

Cardiorenal Protection in Diabetic Kidney Disease.

Over the last 5 years there have been many new developments in the management of diabetic kidney disease. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter-2 (SGLT2) inhibitors were initially used for glycemic control, but more recent studies have now shown that their benefits extend to cardiovascular and kidney outcomes. The recent addition of data on the novel mineralocorticoid receptor antagonist (MRA) gives us another approach to further decrease the residual risk of diabetic kidney disease progression. In this review we describe the mechanism of action, key studies, and possible adverse effects related to these three classes of medications. The management of type 2 diabetes now includes an increasing number of medications for the management of comorbidities in a patient population at significant risk of cardiovascular disease and progression of chronic kidney disease. It is from this perspective that we seek to outline the rationale for the sequential and/or combined use of SGLT2 inhibitors, GLP-1 RA and MRAs in patients with type 2 diabetes for heart and kidney protection.

Interaction of Parenting Style of Mothers and Paediatric Diabetes Management

Background. Parent-child relationship and parenting style are very important for the child’s mental and physical health. This study was focused on investigating the association between mothers’ parenting style (PS) and their children’s with type I diabetes (T1DM) disease management. We hypothesized that mothers’ PS interact with their children’s T1DM outcomes. Methods. One hundred thirty-one mothers, the main caregivers of their diabetic children, filled in the parenting style and demographic questionnaires. The indicator of diabetes management was Haemoglobin A1c (HbA1c) – the main form of glycosylated haemoglobin. PS scales and subscales were associated with glycaemic management indices. Binary logistic regression analysis was applied for the assessment of the association between mothers’ PS and their children’s with T1DM disease management. Results. While logistic regression analysis did not demonstrate statistically significant interaction of T1DM management and mothers’ PS scales and subscales, cluster analysis showed that in the confrontation with T1DM, the relationships between children and parents were dominated by negative elements of PS: lack of emotional warmth, support, reasoning and especially democratic participation. Conclusion. Children’s T1DM management and their mothers’ PS scales and subscales did not demonstrate statistically significant interaction. PS negative elements dominate in mothers’ upbringing: lack of emotional warmth, support, reasoning and especially democratic participation. Keywords: type 1 diabetes, parenting skills, parenting style, diabetes management.

Discussing diabetes, palliative and end of life care: choosing the 'right' language.

Palliative care and advance care planning are important components of diabetes and other chronic disease management plans. Most people with diabetes do not have conversations about palliative/end of life (EOL) care or advance care directives; often because diabetes clinicians are reluctant to discuss these issues. Guidelines for conversations and decision aids can assist shared decision-making for both clinicians and patients. The aim was to co-design information with older people with diabetes, families and clinicians to facilitate conversations about palliative and EOL care and to identify the language (words) people with diabetes, families and diabetes clinicians use to discuss death and dying. We co-designed and tailored the information with advisory groups: (I) older people with diabetes/families, (II) interdisciplinary expert clinicians and undertook a scoping literature review to identify relevant content. The penultimate versions were independently evaluated in focus groups and via written feedback from representative stakeholder clinicians, people with diabetes and international experts in communication, palliative care and diabetes. The information met design and language criteria: 62 people participated in focus groups (48 clinicians, 14 older people with diabetes and 4 family members). There were important differences between people with diabetes and diabetes clinicians concerning the words used to refer to death: 'the language of death'. Diabetes clinicians choose soft words/euphemisms such as 'passed away' and 'gone' and indicated they mirrored patient language. People with diabetes preferred clear language and indicated euphemisms were confusing and misleading. Diabetes clinicians, rarely encountered death in their practice and indicated they lacked education about how to discuss diabetes EOL care. Co-design with key end-users improved relevance to these groups. Diabetes clinicians prefer to use euphemisms for death and would benefit from education and strategies to help them initiate conversations about EOL diabetes care.

Influence of Framing: Recruitment to a Diabetes Disease Management Program From an Emergency Department Improves Enrollment and Outcomes

IntroductionDisease management programs (DMPs) provide education, self-management skills, care coordination, and frequent clinical assessment and medication adjustment. Our health system’s diabetes mellitus (DM) DMP recruited patients from an emergency department (ED) and outpatient settings (primary care physicians’ [PCP] and endocrinologists’ offices; cold calling patients with poorly-controlled diabetes). We investigated whether recruitment to a DMP from an ED is feasible and effective, hypothesizing such patients would have better enrollment rates, future A1c control, and ED utilization because their receptiveness to change was “framed” by their ED visit. “Framing” is the notion that the same problem presented using a different context impacts response to the information. Being told in an acute-care ED setting one has newly-diagnosed or poorly-controlled DM, or DM-related complications may influence desire/commitment to enroll in the DMP and make lifestyle/medication changes. That is, acute illness or acute setting may influence/”frame” willingness to enroll and improve glycemic control. MethodsWe captured all DMP recruitees’ demographic, medical, insurance, A1c, and recruitment venue characteristics and evaluated future enrollment rates, A1c, and ED utilization from any ED in our health system. We analyzed pre- vs. post-recruitment changes in A1c and ED visit rates, comparing patients recruited from the ED who enrolled, patients recruited from the ED who did not enroll, patients recruited from outpatient settings who enrolled, and patients recruited from outpatient settings who did not enroll. Continuous enrollment predictor and outcome variables were compared using the Mann-Whitney test; categorical outcome variables were compared using Fisher’s exact test.ResultsThere were no statistically significant differences in characteristics (including mean baseline A1c [~11.4%]) among patients recruited from the ED, clinics, or cold calling. Twenty-five percent of all ED-recruited patients enrolled vs. 35% from outpatient settings. When a recruiter familiar with the DMP was in the ED, 41% of ED patients enrolled vs. 12% at other times (p=0.0001). Nearly 84% of ED visits were for direct DM-related causes (eg, diabetic ketoacidosis, hyperosmolar hyperglycemic state) or complications with a well-established link to diabetes (eg, acute coronary syndrome, stroke, wound infection); there was no statistically-significant difference in enrollment rates between patients whose ED visit was vs. was not for a DM-related complaint (53.8% vs. 60.0%, p=0.8018). No other variables, including whether the patient had newly diagnosed DM, were associated with enrollment. Enrollees with worse baseline glycemic control (A1c ≥11%) had a greater median A1c decrease (3.5% vs. 1.9%) vs. those with less-poor baseline glycemic control (A1c <11%) or those declining the program (p=0.05). Post-recruitment ED visits-per-patient-per-month decreased among patients recruited from the ED (-0.08), but not among those recruited from outpatient settings. (+0.08), p<0.0001).ConclusionED recruitment to a diabetes DMP is feasible and effective. An ED-based diabetes DMP recruiter had enrollment rates substantially greater than a cold-calling DMP recruiter, comparable to enrollment rates from PCPs and endocrinologists, suggesting the importance of the recruitment framing/context. ED-recruited patients achieved substantial improvements in A1c and future ED visit rates.

Paediatric Type1 Diabetes Management and Mothers' Emotional Intelligence Interactions.

The functioning of the parents’ emotional sphere is very important to a child’s mental and physical health. This study focused on investigating the association between mothers’ emotional intelligence (EI) and paediatric type I diabetes (T1DM) disease management in their children. We hypothesized that mothers’ EI is associated with T1DM outcomes. Mothers of children with T1DM aged 6–12 years were surveyed. One hundred and thirty-four mothers, the main caregivers of their diabetic children, provided measures of EI and completed a demographic questionnaire. The primary indicator of diabetes management was haemoglobin A1c (HbA1c; the main form of glycosylated haemoglobin). EI scales and subscales were associated with glycaemic management indices. Logistic regression analysis was applied for the assessment of the association between parents’ EI and their paediatric with T1DM disease management. The analysis demonstrated a statistically significant correlation between T1DM management and mothers’ ability to understand and control own emotions, to transform their own negative emotions into positive and to control own negative emotions. Mothers’ EI scales and subscales of understanding and regulating their own emotions, subscales of transforming their own negative emotions into positive ones and controlling their own negative emotions were statistically reliable predictors of glycaemic control in children with T1DM.

Self-Efficacy as a Predictor of Self-Management Behavior Practice Among People with Type 2 Diabetes Mellitus (T2DM)

Diabetes mellitus is a major health challenge associated with morbidity and mortality. Self-management behaviors are a critical part of diabetes disease management. Empowered or activated patients are more likely to practice better implementation of self-management behaviors. However, self-management behavior practice has not always been applied effectively among these populations. Further investigations are necessary to evaluate the status and factors that influence the practice of selfmanagement behaviors among patients with diabetes. The purpose of this research is to identify the relationship between self-efficacy and self-management behaviors of people with type 2 Diabetes Mellitus. A cross-sectional research design was used in this study; 112 eligible people with type 2 Diabetes were recruited. Several questionnaires were used in this study including demographic and patient characteristics, Diabetes Management Self Efficacy Scale (DMSES), Summary Diabetes Self Care Activity (SDSCA), and Diabetes Knowledge (DKN) Scale. Data analysis was performed through univariate, bivariate, and multivariate analyzes. Most of the respondents studied were women, aged 34-74 years and the highest educational background was secondary education, 33.9% of respondents have a good level of knowledge, and 59.8% have good self-efficacy. The results show the significant relationship between self-efficacy and self-management behaviors (p-value &lt; 0.001). The results of multivariate analysis showed that there was a relationship between self-efficacy and self-management behavior after being controlled by the knowledge and the duration of diabetes. Therefore, nurses need to improve the self-efficacy of people with type 2 Diabetes by providing education about the management of Diabetes, as well as supporting and motivating them.&#x0D; &#x0D; Keywords: self-efficacy, self-management behaviors, people with type 2 Diabetes Mellitus

Update on diagnosis, pathophysiology, and management of diabetic kidney disease

Diabetic kidney disease (DKD) is a chronic complication of diabetes mellitus which may eventually lead to end-stage kidney disease (ESKD). Despite improvements in glycaemic control and blood pressure management with renin-angiotensin-aldosterone system (RAAS) blockade, the current therapy cannot completely halt DKD progression to ESKD in some patients. DKD is a heterogeneous disease entity in terms of its clinical manifestations, histopathology and the rate of progression, which makes it difficult to develop effective therapeutics. It was formerly considered that albuminuria preceded kidney function decline in DKD, but recent epidemiological studies revealed that a distinct group of patients presented kidney dysfunction without developing albuminuria. Other comorbidities, such as hypertension, obesity and gout, also affect the clinical course of DKD. The pathophysiology of DKD is complex and multifactorial, involving both metabolic and haemodynamic factors. These induce activation of intracellular signalling pathways, oxidative stress, hypoxia, dysregulated autophagy and epigenetic changes, which result in kidney inflammation and fibrosis. Recently, two groups of antidiabetic drugs, sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, were demonstrated to provide renoprotection on top of their glucose-lowering effects. Several other therapeutic agents are also being developed and evaluated in clinical trials.

Individual and Community Social Determinants of Health Associated With Diabetes Management in a Mexican American Population.

Background: Diabetes is a major health burden in Mexican American populations, especially among those in the Lower Rio Grande Valley (LRGV) in the border region of Texas. Understanding the roles that social determinants of health (SDOH) play in diabetes management programs, both at the individual and community level, may inform future intervention strategies.Methods: This study performed a secondary data analysis on 1,568 individuals who participated in Salud y Vida (SyV), a local diabetes and chronic disease management program, between October 2013 and September 2018 recruited from a local clinic. The primary outcome was the reduction of hemoglobin A1C (HbA1C) at the last follow-up visit compared to the baseline. In addition to age, gender, insurance status, education level and marital status, we also investigated 15 community (census tract) SDOH using the American Community Survey. Because of the high correlation in the community SDOH, we developed the community-level indices representing different domains. Using Bayesian multilevel spatial models that account for the geographic dependency, we were able to simultaneously investigate the individual- and community-level SDOH that may impact HbA1C reduction.Results: After accounting for the diabetes self-management education classes taken by the participants and their length of stay in the program, we found that older age at baseline, being married (compared to being widowed or divorced) and English speaking (compared to Spanish) were significantly associated with greater HbA1C reduction. Moreover, we found that the community level SDOH were also highly associated with HbA1C reduction. With every percentile rank decrease in the socioeconomic advantage index, we estimated an additional 0.018% reduction in HbA1C [95% CI (−0.028, −0.007)]. Besides the socioeconomic advantage index, urban core opportunity and immigrant's cohesion and accessibility indices were also statistically associated with HbA1C reduction.Conclusion: To our knowledge, our study is the first to utilize Bayesian multilevel spatial models and simultaneously investigate both individual- and community-level SDOH in the context of diabetes management. Our findings suggest that community SDOH play an important role in diabetes control and management, and the need to consider community and neighborhood context in future interventions programs to maximize their overall effectiveness.

Plants of the Spontaneous Flora with Beneficial Action in the Management of Diabetes, Hepatic Disorders, and Cardiovascular Disease.

The current pharmacological agents advised for the management of diabetes as well as cardiovascular and hepatic diseases are subject to numerous studies for safety and efficacy. Therefore, it is worth looking into alternative therapeutic aids such as natural products of medicinal plants. By a broad review of in vitro and in vivo studies on the various dandelion, chicory, and mulberry extracts, this work highlights their bioactive compounds and therapeutic action when used as a prevention and management aid in public health such as diabetes, cardiovascular disease, and hepatic disorders like non-alcoholic steatohepatitis. Natural products of dandelion leaves and root extracts can suppress the development of liver cancer, decrease insulin resistance, and suppress total triglyceride and cholesterol levels. Recent studies on mulberry leaves extracts indicated that they could decrease palmitic acid-induced lipotoxicity, increase total cholesterol and bile acid excretion, improve superoxide dismutase expression, and improve insulin resistance. Chicory root extracts boost satiety, reverse insulin resistance, and augment lipid metabolism thanks to their contents in chicoric acid, chlorogenic acid, and polysaccharides. Taraxacum officinale L., Morus nigra L., and Cichorium intybus L. present hepatoprotective, anti-inflammatory, antioxidant, hypolipidemic, and hypoglycemic activities and are shown to be advantageous in the management of obesity, dyslipidemia, Type 2 diabetes, and non-alcoholic fatty liver diseases. These plants are commonly available in the European spontaneous flora and more attention could be paid to their natural products.

Diabetic Foot Disease during the COVID-19 Pandemic.

Throughout 2020, the COVID-19 pandemic has had a major impact on the care of non-communicable diseases across the world and diabetes is no exception. Whereas many branches of medicine have adapted to telemedicine, this is difficult and challenging for the diabetic foot which often requires “hands on” treatment. This review covers the challenges that have faced clinicians across the world in the management of complex diabetic foot problems and also includes some illustrative case vignettes which show how it is possible to manage foot ulcers without the usual access to laboratory and radiological testing. There is no doubt that the COVID-19 experience when handling diabetic foot problems will likely transform our approach to the management of diabetic foot disease especially in the areas of digital health and smart technology.

Diabetic eye disease: A review of screening and management recommendations.

The prevalence of diabetes is rapidly increasing, and it is now the leading cause of blindness worldwide. Although early detection of diabetic retinopathy is key to preventing vision loss, many patients do not receive appropriate examinations. Using a multidisciplinary approach, primary care physicians and eye care providers should follow evidence-based recommendations for screening and monitoring diabetic patients while working to improve patients' glycaemic index, blood pressure, and metabolic risk factors. Anti-vascular endothelial growth factor intravitreal injections in combination with panretinal photocoagulation and focal laser treatment remain the cornerstones of modern therapy. The many landmark studies for diabetic eye disease management should guide counselling and decision making for treating diabetic macular oedema, proliferative retinopathy and other diabetes-related eye diseases.

Patterns of chronic disease management and health outcomes in a population-based cohort of Black women with breast cancer.

Diabetes and hypertension are two common comorbidities that affect breast cancer patients, particularly Black women. Disruption of chronic disease management during cancer treatment has been speculated. Therefore, this study examined the implementation of clinical practice guidelines and health outcomes for these comorbidities before and during cancer treatment. We used a population-based, prospective cohort of Black women diagnosed with breast cancer (2012-2016) in New Jersey (n = 563). Chronic disease management for diabetes and hypertension was examined 12 months before and after breast cancer diagnosis and compared using McNemar's test for matched paired and paired t tests. Among this cohort, 18.1% had a co-diagnosis of diabetes and 47.2% had a co-diagnosis of hypertension. Implementation of clinical practice guidelines and health outcomes that differed in the 12 months before and after cancer diagnosis included lipid screening (64.5% before versus 50.0% after diagnosis; p = 0.004), glucose screening (72.7% versus 90.7%; p < 0.001), and blood pressure control < 140/90mmHg (57.6% versus 71.5%; p = 0.004) among patients with hypertension-only. For patients with diabetes, eye and foot care were low (< 35%) and optimal HbA1c < 8.0% was achieved for less than 50% of patients in both time periods. Chronic disease management continued during cancer treatment; however, eye and foot exams for patients with diabetes and lipid screening for patients with hypertension-only were inadequate. Given that comorbidities may account for half of the Black-White breast cancer survival disparity, strategies are needed to improve chronic disease management during cancer, especially for Black women who bear a disproportionate burden of chronic diseases.

Review on diabetes disease management programs

To comprehensively review and integrate available data on the impact of diabetes treatment programs on care procedures and outcomes for patients with diabetes mellitus. Review of literature and morph were used in this study. From 1987 to 2001, computerized databases was conducted for English-language controlled trials evaluating the efficacy of diabetic disease management regimens. Using a standardized abstraction form, two independent reviewers collected research data. An empirical Bayes model was used to generate pooling estimates of program impacts on glycosylated hemoglobin. The pooled assessment of program effects on glycosylated hemoglobin was a 0.5-percentage-point decrease (95 percent confidence range, 0.3 to 0.6 percentage points), which is a small but substantial improvement. Research strongly supports the program's advantages in improving retinal and foot lesions screening. Diabetic programs may help to enhance glucose control and boost retinal and foot problems screening. For individuals with diabetes mellitus, greater effort will be needed to develop more successful disease management strategies.

Knowledge, Attitudes and Practices (KAP) of Type 2 Diabetes and Chronic Kidney Disease Management among Patients Visiting GeneralPhysicians in Islamabad: A Cross-Sectional Study

Aim: Diabetes is one of the major causes of Chronic Kidney Disease (CKD). Epidemiological studies revealed a low knowledge of the general population about the disease. This study is aimed to identify the Knowledge, Attitude, and Practices (KAP) of patients with Type 2 Diabetes (T2D) and Chronic Kidney Disease (CKD) of patients in Islamabad (Capital city of Pakistan) who visited their family physicians from Dec 01, 2020, to Feb 28, 2021. Methods: A quantitative, cross-sectional study using a validated questionnaire involving residents of Islamabad, earlier diagnosed with T2D and CKD, equal to or above 25 years of age, who visited their family physicians during the study period. Eligible participants were identified using purposive sampling. Questions about knowledge, attitude, and practices of disease management were asked. Results: A high level of Knowledge, Attitude, and Practice (KAP) was observed in the majority of study participants. A few areas of low knowledge identified were the understanding of the relationship between high blood pressure and CKD and the treatment of renal disease with dialysis. Attitudes regarding disease prevention, outcome, and burden were high but the impact and management of renal disease were low. High practices of prevention, consultation, behavior, modification were seen but practices of disease self-management, usage of traditional herbal medicinal substitutes, and frequent clinical visits were low. Conclusions: While most of the areas indicated a high level of knowledge, attitude, and practices some low-level areas were noticed. These should be the target of future interventions and public health programs for T2D and CKD for further improvement of KAP scores. Similar studies should be conducted among other population subgroups in other parts of the country. Targeted interventions/public health programs catering to the needs of all communities should be implemented and evaluated for their effectiveness to improve the overall level of healthcare in the country.