XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

ACS
: acute coronary syndrome
AMPLIFY
: Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-line Therapy
aPTT
: activated partial thromboplastin time
b.i.d.
: bis in diem (twice daily)
b.p.m.
: beats per minute
BNP
: brain natriuretic peptide
BP
: blood pressure
CI
: confidence interval
CO
: cardiac output
COPD
: chronic obstructive pulmonary disease
CPG
: Committee for Practice Guidelines
CRNM
: clinically relevant non-major
CT
: computed tomographic/tomogram
CTEPH
: chronic thromboembolic pulmonary hypertension
CUS
: compression venous ultrasonography
DSA
: digital subtraction angiography
DVT
: deep vein thrombosis
ELISA
: enzyme-linked immunosorbent assay
ESC
: European Society of Cardiology
H-FABP
: heart-type fatty acid-binding protein
HIT
: heparin-induced thrombocytopenia
HR
: hazard ratio
ICOPER
: International Cooperative Pulmonary Embolism Registry
ICRP
: International Commission on Radiological Protection
INR
: international normalized ratio
iPAH
: idiopathic pulmonary arterial hypertension
IVC
: inferior vena cava
LMWH
: low molecular weight heparin
LV
: left ventricle/left ventricular
MDCT
: multi-detector computed tomographic (angiography)
MRA
: magnetic resonance angiography
NGAL
: neutrophil gelatinase-associated lipocalin
NOAC(s)
: Non-vitamin K-dependent new oral anticoagulant(s)
NT-proBNP
: N-terminal pro-brain natriuretic peptide
o.d.
: omni die (every day)
OR
: odds ratio
PAH
: pulmonary arterial hypertension
PE
: pulmonary embolism
PEA
: pulmonary endarterectomy
PEITHO
: Pulmonary EmbolIsm THrOmbolysis trial
PESI
: pulmonary embolism severity index
PH
: pulmonary hypertension
PIOPED
: Prospective Investigation On Pulmonary Embolism Diagnosis
PVR
: pulmonary vascular resistance
RIETE
: Registro Informatizado de la Enfermedad Thromboembolica venosa
RR
: relative risk
rtPA
: recombinant tissue plasminogen activator
RV
: right ventricle/ventricular
SPECT
: single photon emission computed tomography
sPESI
: simplified pulmonary embolism severity index
TAPSE
: tricuspid annulus plane systolic excursion
Tc
: technetium
TOE
: transoesophageal echocardiography
TTR
: time in therapeutic range
TV
: tricuspid valve
UFH
: unfractionated heparin
V/Q scan
: ventilation–perfusion scintigraphy
VKA
: vitamin K antagonist(s)
VTE
: venous thromboembolism

Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk-benefit-ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help the health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.

A great number of Guidelines have …

/pdf/2014-esc-guidelines-on-the-diagnosis-and-management-of-acute-1f9ulv0b8w.pdf

2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism

Hyperglycemia and Adverse Pregnancy Outcomes

Objective To determine the clinical manifestations, risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed coronavirus disease 2019 (covid-19). Design Living systematic review and meta-analysis. Data sources Medline, Embase, Cochrane database, WHO COVID-19 database, China National Knowledge Infrastructure (CNKI), and Wanfang databases from 1 December 2019 to 6 October 2020, along with preprint servers, social media, and reference lists. Study selection Cohort studies reporting the rates, clinical manifestations (symptoms, laboratory and radiological findings), risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed covid-19. Data extraction At least two researchers independently extracted the data and assessed study quality. Random effects meta-analysis was performed, with estimates pooled as odds ratios and proportions with 95% confidence intervals. All analyses will be updated regularly. Results 192 studies were included. Overall, 10% (95% confidence interval 7% to 12%; 73 studies, 67 271 women) of pregnant and recently pregnant women attending or admitted to hospital for any reason were diagnosed as having suspected or confirmed covid-19. The most common clinical manifestations of covid-19 in pregnancy were fever (40%) and cough (41%). Compared with non-pregnant women of reproductive age, pregnant and recently pregnant women with covid-19 were less likely to have symptoms (odds ratio 0.28, 95% confidence interval 0.13 to 0.62; I2=42.9%) or report symptoms of fever (0.49, 0.38 to 0.63; I2=40.8%), dyspnoea (0.76, 0.67 to 0.85; I2=4.4%) and myalgia (0.53, 0.36 to 0.78; I2=59.4%). The odds of admission to an intensive care unit (odds ratio 2.13, 1.53 to 2.95; I2=71.2%), invasive ventilation (2.59, 2.28 to 2.94; I2=0%) and need for extra corporeal membrane oxygenation (2.02, 1.22 to 3.34; I2=0%) were higher in pregnant and recently pregnant than non-pregnant reproductive aged women. Overall, 339 pregnant women (0.02%, 59 studies, 41 664 women) with confirmed covid-19 died from any cause. Increased maternal age (odds ratio 1.83, 1.27 to 2.63; I2=43.4%), high body mass index (2.37, 1.83 to 3.07; I2=0%), any pre-existing maternal comorbidity (1.81, 1.49 to 2.20; I2=0%), chronic hypertension (2.0, 1.14 to 3.48; I2=0%), pre-existing diabetes (2.12, 1.62 to 2.78; I2=0%), and pre-eclampsia (4.21, 1.27 to 14.0; I2=0%) were associated with severe covid-19 in pregnancy. In pregnant women with covid-19, increased maternal age, high body mass index, non-white ethnicity, any pre-existing maternal comorbidity including chronic hypertension and diabetes, and pre-eclampsia were associated with serious complications such as admission to an intensive care unit, invasive ventilation and maternal death. Compared to pregnant women without covid-19, those with the disease had increased odds of maternal death (odds ratio 2.85, 1.08 to 7.52; I2=0%), of needing admission to the intensive care unit (18.58, 7.53 to 45.82; I2=0%), and of preterm birth (1.47, 1.14 to 1.91; I2=18.6%). The odds of admission to the neonatal intensive care unit (4.89, 1.87 to 12.81, I2=96.2%) were higher in babies born to mothers with covid-19 versus those without covid-19. Conclusion Pregnant and recently pregnant women with covid-19 attending or admitted to the hospitals for any reason are less likely to manifest symptoms such as fever, dyspnoea, and myalgia, and are more likely to be admitted to the intensive care unit or needing invasive ventilation than non-pregnant women of reproductive age. Pre-existing comorbidities, non-white ethnicity, chronic hypertension, pre-existing diabetes, high maternal age, and high body mass index are risk factors for severe covid-19 in pregnancy. Pregnant women with covid-19 versus without covid-19 are more likely to deliver preterm and could have an increased risk of maternal death and of being admitted to the intensive care unit. Their babies are more likely to be admitted to the neonatal unit. Systematic review registration PROSPERO CRD42020178076. Readers’ note This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This version is update 1 of the original article published on 1 September 2020 (BMJ 2020;370:m3320), and previous updates can be found as data supplements (https://www.bmj.com/content/370/bmj.m3320/related#datasupp). When citing this paper please consider adding the update number and date of access for clarity.

https://www.bmj.com/content/bmj/370/bmj.m3320.full.pdf

Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.

Clinical prediction models combine multiple predictors to estimate risk for the presence of a particular condition (diagnostic models) or the occurrence of a certain event in the future (prognostic models). PROBAST (Prediction model Risk Of Bias ASsessment Tool), a tool for assessing the risk of bias (ROB) and applicability of diagnostic and prognostic prediction model studies, was developed by a steering group that considered existing ROB tools and reporting guidelines. The tool was informed by a Delphi procedure involving 38 experts and was refined through piloting. PROBAST is organized into the following 4 domains: participants, predictors, outcome, and analysis. These domains contain a total of 20 signaling questions to facilitate structured judgment of ROB, which was defined to occur when shortcomings in study design, conduct, or analysis lead to systematically distorted estimates of model predictive performance. PROBAST enables a focused and transparent approach to assessing the ROB and applicability of studies that develop, validate, or update prediction models for individualized predictions. Although PROBAST was designed for systematic reviews, it can be used more generally in critical appraisal of prediction model studies. Potential users include organizations supporting decision making, researchers and clinicians who are interested in evidence-based medicine or involved in guideline development, journal editors, and manuscript reviewers.

/pdf/probast-a-tool-to-assess-the-risk-of-bias-and-applicability-250aflps2y.pdf

PROBAST: A tool to assess the risk of bias and applicability of prediction model studies

Objective: Description of characteristics, risk factors, management strategies and maternal, obstetric and neonatal outcomes of SARS-CoV-2 infected pregnant women in the Netherlands. Design: Multi-centre prospective nationwide population-based cohort study. Setting: Nationwide. Population: All pregnant women in the Netherlands with confirmed SARS-CoV-2 infection in home-isolation or admitted to hospital between March 1st, 2020 and August 31st, 2020. Methods: Pregnant women with positive PCR or antibody tests were registered using the Netherlands Obstetrics Surveillance System. Testing occurred according to national guidelines (selective testing). Data from the national birth registry (Perined) and Dutch National Institute for Public Health and the Environment (RIVM) were used as reference. Main Outcome Measures: Incidence of pregnant women with SARS-CoV-2 infection. Maternal, obstetric and neonatal outcomes including hospital and critical care admission, clinical management and mode of birth. Results: Of 312 registered women, 65 (20%) were admitted to hospital, of whom 5 (2%) to intensive care and 9 (14%) to obstetric high care units. Risk factors for admission were non-Caucasian background (n=28; OR 6.67, 95%CI 4.08-10.90) and being overweight or obese (n=38; OR 2.64, 95%CI1.51 to 4.61). Hospital and intensive care admission were higher compared to age-matched infected women (respectively, OR 14.57, 95%CI 10.99-19.03 and OR 5.02, 95%CI 2.04-12.34). One maternal death occurred. Caesarean section after labour onset was increased (OR 2.50; 95%CI 1.57-3.97). Conclusions: Pregnant women with SARS-CoV-2 infection are at increased risk of hospital admission, ICU admission and caesarean section. Funding: No funding was received. Keywords: Pregnancy, COVID-19, SARS-CoV-2, Pregnancy complications, Pregnancy outcome, Obstetric surveillance system.

/pdf/sars-cov-2-infection-in-pregnancy-during-the-first-wave-of-2n10zactv7.pdf

SARS-CoV-2 infection in pregnancy during the first wave of COVID-19 in the Netherlands: a prospective nationwide population-based cohort study

Background A uterine scar is a well-known riskfactorfor both abnormal placentation and uterine rupture, both of which may lead to a serious obstetric hemorrhage. Case A 23-year-old woman, gravida 2, para 0 with a history of first-trimester dilatation and curettage (D&C) experienced a life-threatening obstetric hemorrhage due to uterine rupture during manual removal of a placenta increta. Cessation of the bleeding occurred only following secondary embolization after hysterectomy. Conclusion Obstetricians should be aware of the risk of uterine scarring and abnormal placentation in women who have undergone D&C, as it could lead to a life-threatening obstetric hemorrhage.

Nearly fatal uterine rupture during manual removal of the placenta: a case report.

To analyze outcomes of nationwide local audits of uterine rupture to draw lessons for clinical care.

Lessons learned from the perinatal audit of uterine rupture in the Netherlands: A mixed‐method study

Er is groeiende belangstelling voor ernstige maternale morbiditeit als kwaliteitsindicator in de verloskunde.1-4 Een belangrijke reden hiervoor is de zeer lage frequentie van moedersterfte in westerse landen. Hierdoor duurt het jaren voordat oorzaken van en trends in moedersterfte kunnen worden waargenomen. Bovendien lijkt moedersterfte steeds vaker het gevolg te zijn van zeldzame complicaties, terwijl de vaker voorkomende verloskundige complicaties zoals massale fl uxus post partum relatief ondervertegenwoordigd zijn omdat die meestal niet tot moedersterfte leiden. Tegelijkertijd is er vanuit de overheid de laatste jaren in Nederland veel aandacht voor kwaliteitsindicatoren in de medische zorg. Vooral op het gebied van de verloskunde is dit mede ingegeven door de vermeende zorgelijke ontwikkelingen op het gebied van de perinatale sterfte in ons land.5 Verscheidene internationale onderzoeksgroepen hebben getracht een universeel hanteerbare defi nitie van ernstige maternale morbiditeit te formuleren. De Wereldgezondheidsorganisatie (WHO) probeert momenteel deze inspanningen te integreren in internationaal geaccepteerde criteria voor ernstige maternale morbiditeit.6-9 Recente onderzoeken laten een toename zien van ernstige DOEL Vaststellen van frequentie, letaliteit en risicofac toren van ernstige maternale morbiditeit in Nederland, en beoordelen van substandaard fac toren. OPZET Prospec tief populatiegebaseerd cohor tonderzoek onder alle 98 verloskundeafdelingen in Nederland. METHODEN Alle gevallen van ernstige maternale morbiditeit werden verzameld gedurende een periode van 2 jaar. Alle bevallingen in Nederland gedurende dezelfde periode dienden als referentiecohor t (n = 371.021). Vanwege de over ver tegenwoordiging van niet-westerse immigranten in de moederster f testatistieken was er speciale aandacht voor etnische af komst. In een subgroep van 2,5% van alle gevallen werden substandaard zorgaspec ten beoordeeld tijdens auditbijeenkomsten door het land. RESULTATEN Er werden in totaal 2552 gevallen van ernstige maternale morbiditeit gerappor teerd. De frequentie was 7,1 per 1000 bevallingen. Er waren 847 IC-opnames (2,4 per 1000), 218 gevallen van uterusruptuur (6,1 per 10.000), 222 gevallen van eclampsie (6,2 per 10.000) en 1606 gevallen van ernstige f luxus (4,5 per 1000). Niet-westerse immigranten hadden een 1,3 maal zo hoog risico op ernstige maternale morbiditeit als westerse vrouwen (95%-BI: 1,2-1,5). De letaliteit was 1 op 53. Substandaard zorg werd gevonden in 39 van de 63 geanalyseerde gevallen (62%). CONCLUSIE Ernstige maternale morbiditeit compliceer t tenminste 0,71% van de bevallingen in Nederland, waarbij immigranten een verhoogd risico hebben. Aangezien substandaard zorg zich in de meerderheid van de beoordeelde gevallen voordeed, kan ernstige maternale morbiditeit verder worden gereduceerd.

Ernstige maternale morbiditeit tijdens zwangerschap, bevalling en kraambed in Nederland

Timing of plasma transfusion and maternal mortality and severe maternal morbidity in women with persistent postpartum haemorrhage: the Tempoh-1 study

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