Impact of clinical inertia on cardiovascular risk factors in patients with diabetes.

AIMS: To determine whether clinical inertia is associated with simpler interventions occurring more often than complex changes and the association between clinical inertia and outcomes. METHODS: Prevalence of clinical inertia over a 30 month period for hyperglycaemia, hypertension and dyslipidaemia was calculated in a random sample (n=334) of patients attending a diabetes clinic. Comparisons between prevalence of clinical inertia and outcomes for each condition were examined using parametric tests of association. RESULTS: There was less clinical inertia in hyperglycaemia (29% of consultations) compared with LDL (80% of consultations) and systolic BP (68% of consultations). Consultations where therapy was intensified had a greater reduction in risk factor levels than when no change was made. No association was found between treatment intensity scores and changes in HbA1c, LDL or blood pressure over 30 months. CONCLUSIONS: Physicians are no more likely to intervene in conditions where simple therapeutic changes are necessary as opposed to complex changes. Greater clinical inertia leads to poorer outcomes. There continues to be substantial clinical inertia in routine clinical practice. Physicians should adopt a holistic approach to cardiovascular risk reduction in patients with diabetes, adhere more closely to established management guidelines and emphasize personal individualized target setting.

Clinical audit of diabetes care in the bahrain defence forces hospital.

OBJECTIVES: Primary care audits in Bahrain have consistently revealed a failure to meet recognised standards of delivery of process and outcome measures to patients with diabetes. This study aimed to establish for the first time the quality of diabetes care in a Bahraini hospital setting. METHODS: A retrospective clinical audit was conducted of a random sample of patients attending the Diabetes and Endocrine Center at the Bahrain Defence Forces Hospital over a 15-month period which ended in June 2010. The medical records of 287 patients with diabetes were reviewed electronically and manually for process and outcome measures, and a statistical analysis was performed. RESULTS: Of the patients, 47% were male, with a median age of 54 years, and 5% had type 1 diabetes. Measured processes, including haemoglobin A1c, blood pressure, lipids, creatinine and weight, were recorded in over 90% of the patients. Smoking (8%) and the patient's body mass index (19%) were less frequently recorded. Screening for complications was low, with retinal screening in 42%, foot inspection in 22% and microalbuminuria in 23% of patients. CONCLUSION: This study shows that the implementation of recognised evidence-based practice continues to pose challenges in routine clinical care. Screening levels for the complications of diabetes were low in this hospital diabetes clinic. It is important to implement a systematic approach to diabetes care to improve the quality of care of patients with diabetes which could lead to a lowering of cardiovascular risk and a reduction in healthcare costs in the long term.

Comparative evaluation of the degree of pegylation of poly(lactic-co-glycolic acid) nanoparticles in enhancing central nervous system delivery of loperamide.

OBJECTIVES: In this study, we examined the relative cellular uptake of nanoparticles (NPs) formulated using poly(lactic-co-glycolic acid) (PLGA) polymers with increasing degree of pegylation (PLGA-PEG) and their potential to deliver loperamide to the brain of a mouse. METHOD: NPs containing coumarin-6 or loperamide HCl were formulated using PLGA and PLGA-PEG, with PEG content of 5-15%, by the solvent evaporation method. NPs were characterised for size, surface charge, morphology, encapsulation efficiency and drug release. Cellular uptake of coumarin-6 NPs was examined in Caco-2 monolayers using confocal microscopy and central nervous system (CNS) delivery of loperamide HCl from the NPs was examined following intranasal administration in a mouse model. KEY FINDINGS: No difference in NP characteristics was observed, irrespective of degree of pegylation, except for the surface charge which increased with increasing PEG content. PLGA-PEG NPs were found to have increased cellular uptake in comparison to PLGA NPs. Interestingly, this pattern was reflected in the CNS delivery of loperamide HCl in the mouse model. CONCLUSION: The results from this study show that PLGA-PEG NPs have the potential to act as carriers for the noninvasive administration of therapeutic agents to the brain and possibly across other physiological barriers.