Management of dyslipidemia and atherosclerotic cardiovascular risk in prediabetes.

Prediabetes affects at least 1 in 3 adults in the U.S. and 1 in 5 in Europe. Although guidelines advocate aggressive management of lipid parameters in diabetes, most guidelines do not address treatment of dyslipidemia in prediabetes despite the increased atherosclerotic cardiovascular disease (ASCVD) risk. Several criteria are used to diagnose prediabetes: impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and HbA1c of 5.7-6.4%. Individuals with prediabetes have a greater risk of diabetes, a higher prevalence of dyslipidemia with a more atherogenic lipid profile and an increased risk of ASCVD. In addition to calculating ASCVD risk using traditional methods, an OGTT may further stratify risk. Those with 1-hour plasma glucose ≥8.6 mmol/L (155 mg/dL) and/or 2-hour ≥7.8 mmol/L (140 mg/dL) (IGT) have a greater risk of ASCVD. Diet and lifestyle modification are fundamental in prediabetes. Statins, ezetimibe and PCSK9 inhibitors are recommended in people requiring pharmacotherapy. Although high-intensity statins may increase risk of diabetes, this is acceptable because of the greater reduction of ASCVD. The LDL-C goal in prediabetes should be individualized. In those with IGT and/or elevated 1-hour plasma glucose, the same intensive approach to dyslipidemia as recommended for diabetes should be considered, particularly if other ASCVD risk factors are present.

Review of methods for detecting glycemic disorders.

Prediabetes (intermediate hyperglycemia) consists of two abnormalities, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) detected by a standardized 75-gram oral glucose tolerance test (OGTT). Individuals with isolated IGT or combined IFG and IGT have increased risk for developing type 2 diabetes (T2D) and cardiovascular disease (CVD). Diagnosing prediabetes early and accurately is critical in order to refer high-risk individuals for intensive lifestyle modification. However, there is currently no international consensus for diagnosing prediabetes with HbA1c or glucose measurements based upon American Diabetes Association (ADA) and the World Health Organization (WHO) criteria that identify different populations at risk for progressing to diabetes. Various caveats affecting the accuracy of interpreting the HbA1c including genetics complicate this further. This review describes established methods for detecting glucose disorders based upon glucose and HbA1c parameters as well as novel approaches including the 1-hour plasma glucose (1-h PG), glucose challenge test (GCT), shape of the glucose curve, genetics, continuous glucose monitoring (CGM), measures of insulin secretion and sensitivity, metabolomics, and ancillary tools such as fructosamine, glycated albumin (GA), 1,5- anhydroglucitol (1,5-AG). Of the approaches considered, the 1-h PG has considerable potential as a biomarker for detecting glucose disorders if confirmed by additional data including health economic analysis. Whether the 1-h OGTT is superior to genetics and omics in providing greater precision for individualized treatment requires further investigation. These methods will need to demonstrate substantially superiority to simpler tools for detecting glucose disorders to justify their cost and complexity.

Pitfalls of HbA1c in the Diagnosis of Diabetes.

Many health care providers screen high-risk individuals exclusively with an HbA1c despite its insensitivity for detecting dysglycemia. The 2 cases presented describe the inherent caveats of interpreting HbA1c without performing an oral glucose tolerance test (OGTT). The first case reflects the risk of overdiagnosing type 2 diabetes (T2D) in an older African American male in whom HbA1c levels, although variable, were primarily in the mid-prediabetes range (5.7-6.4% [39-46 mmol/mol]) for many years although the initial OGTT demonstrated borderline impaired fasting glucose with a fasting plasma glucose of 102 mg/dL [5.7 mmol/L]) without evidence for impaired glucose tolerance (2-hour glucose ≥140-199 mg/dl ([7.8-11.1 mmol/L]). Because subsequent HbA1c levels were diagnostic of T2D (6.5%-6.6% [48-49 mmol/mol]), a second OGTT performed was normal. The second case illustrates the risk of underdiagnosing T2D in a male with HIV having normal HbA1c levels over many years who underwent an OGTT when mild prediabetes (HbA1c = 5.7% [39 mmol/mol]) developed that was diagnostic of T2D. To avoid inadvertent mistreatment, it is therefore essential to perform an OGTT, despite its limitations, in high-risk individuals, particularly when glucose or fructosamine and HbA1c values are discordant. Innate differences in the relationship between fructosamine or fasting glucose to HbA1c are demonstrated by the glycation gap or hemoglobin glycation index.

Pedagogical prattices of good nursing, medicineand dentistry professors from tthe students' perceptonn / Las práctcas peddagógicas de buenos profesores de enfermeía, medicina y odontología en la percepción de estuiaantes / Prátias pedagógiicas de bons professores de enfermage, medicina e oddontologia na percepção dos estudantes

ABSTRACTThe aim of this qualitative study was to analyze, in the light of Shuman's concept of pedagogical content knowledge, the pedagogical practices of good nursing, medicine and dentistry professors from the perception of students of a public university in southern Brazil. The study comprised 16 students who were approached through interviews focused by vignettes and qualitative indicators. Pedagogical content knowledge is observed when good professors share the learning objectives while associating theory and practice, fostering student reasoning using a wide range of strategies responsive to contents and the public; carefully prepare and organize their lessons; and allow to be evaluated. Pedagogical content knowledge is presented as a differential in teaching practice; however, students perceive these practices in few professors, leading to the need for recommending rooms and strategies for training health teaching staff.

RESUMENEste estudio cualitativo tuvo como objetivo analizar a la luz del concepto de conocimiento pedagógico del contenido de Shulman prácticas pedagógicas de buenos profesores de enfermería, medicina y odontología en la percepción de los estudiantes de una universidad pública en el sur de Brasil. Los participantes del estudio fueron 16 estudiantes entrevistados con la ayuda de la entrevista focalizada en viñetas e indicadores cualitativos. El conocimiento del contenido pedagógico muestra esto cuando los buenos profesores comparten los objetivos de aprendizaje mientras se establece la conexión entre la teoría y la práctica, fomentando el razonamiento de los estudiantes usando una amplia gama de estrategias adecuadas a los contenidos y público; prepararan y organizan sus lecciones con cuidado y permiten ser evaluados. El conocimiento didáctico del contenido se presenta como un diferencial en la práctica docente, sin embargo, son pocos los profesores que los estudiantes perciben con estas prácticas, siendo necesaria la propuesta de espacios y estrategias de formación docente y en salud.

RESUMO Estudo qualitativo que teve como objetivo analisar, à luz do conceito de conhecimento pedagógico de conteúdo de Shulman, práticas pedagógicas de bons professores de enfermagem, medicina e odontologia, na percepção de estudantes de uma universidade pública do Sul do Brasil. Participaram do estudo 16 estudantes, entrevistados com auxílio de entrevista focalizada por vinhetas e indicadores qualitativos. O conhecimento pedagógico de conteúdo se mostra presente quando bons professores compartilham os objetivos de ensino ao mesmo tempo em que estabelecem conexão entre teoria e prática, por meio do fomento do raciocínio do estudante utilizando-se de uma diversa gama de estratégias adequadas aos conteúdos e ao público; preparam e organizam suas aulas com esmero; e permitem-se ser avaliados. O conhecimento pedagógico de conteúdo se apresenta como diferencial na prática docente, entretanto, poucos são os professores em quem os estudantes percebem estas práticas, sendo necessária proposição de espaços e estratégias de formação docente em saúde.