Pharmacological Agents Used In The Treatment Of Diabetes …用于治療糖尿病的藥物…

1、The Multi-disciplinary Diabetes Centre : A Model of Care for the Future (or the Past) ? Dennis Yue Director of Diabetes, Royal Prince Alfred Hospital Kellion Professor of Endocrinology, University of Sydney Conference in China The Burden and Complexity of Diabetes Different Models of Diabetes Care D

2、iabetic Clinic Care Diabetes Centre Diabetic Clinic Care + Annual Complications Screening Complications Screening in 12 months (%) Eyes review8810086 Lipids Measurement729692 Microalbuminuria569472 Target Achieved (%) Cholesterol 4mmol/L242427 BP263528 HbA1c within 1% of normal range 294441 ANDIAB S

3、urvey : Cheung NW et al : Diabet Med 2008 ; 25(8) : 974-8 We Must Have A Centre ! A Multi-disciplinary Diabetes Centre Family Doctor Dietitian Diabetes Nurse / Educator Podiatrist Specialist Secretaries ResearcherPerson with Diabetes What We Need Is Not A Diabetes Education Centre Referring Doctor C

4、omplications and Metabolic Management (Type 1 10(1) : 81-6 Overland J et al : Diabetes Res Clin Pract 1999 ; 44(2) : 123-8 Constantino M et al : Med J Aust 1991 ; 155(8) : 515-8 One Stop Complications Assessment McGill M et al : Diabet Med 1993 ; 10(4) : 366-70 McGill M et al :Diabetes Care : 1989 ;

5、 12(8) : 599-600 Standardised Data Capture Younger Onset of Type 2 Diabetes Increases Risk of Retinopathy Wong J et al : Diabetes Care 2008; 10 : 1985-90 Beyond ONTARGET : (Deterioration of renal function while on combined ACE-I and A2 Receptor Blocker Treatment ) Hypertension (BP 160/100 ) J Wong e

6、t al : Diabetes Obesity and Metabolism 2010 Ambulatory Stabilisation of Diabetes : Commencing Insulin Therapy Hoskins PL et al : Med J Aust 1993 ; 158(3) : 148-9 Telephone Stabilisation Genev NM et al Diabet Med 1990 ; (1) : 920-1 Changing Pattern of Treatment of Type 1 Diabetes : More Use of Carboh

7、ydrate Counting and Insulin Pump Continuity of Care in a Multi-disciplinary Setting Visit 1 Visit 2 Visit 3 Visit 4 Patient 1Patient 2 Standardised Format of Letters (Documentation and Education) Infrastructure Support Monitoring By A Senior Nurse After Visits Daily team clinical meeting All patient

8、s medical record reviewed ; possible mistakes identified and appropriately questioned Standardises party line message and upskill staff Collects data The High Risk Diabetic Foot Clinic A Co-ordinator Who Knows Everything McGill M et al : Intern Med J 2005 ; 35(8) : 451-6 Nube VL et al : The Diabetic

9、 Foot Journal 2008 ; 11, 187-193 Benefits of Multi-disciplinary Foot Clinics (RPAH): Prevalence and Level of Amputation DistalBelow Knee Above Knee 0 10 20 30 40 50 60 70 80 90 Clinic No Clinic Percentage of Amputations (%) 2 =14.6; P=0.001 McGill M et al : Intern Med J 2005 ; 35(8) : 451-6 Nube VL

10、et al : The Diabetic Foot Journal 2008 ; 11, 187-193 Medical Data E-mail High Risk Foot Clinics Dubbo Lismore Nowra Orange Grafton Port Macquarie Griffith Forbes Quirindi Mullumbimby How Does Telemedicine Work? McGill M 17(7) : 235-238. Clinical Trials Why is the Multi-disciplinary Diabetes Centre a

11、 Better Model for a Chronic and Complex Disease ? A more stable system than one dependent on rotating doctors Complement better the skill of allied health professionals and doctors ; therefore a broader range of expertise Better stratification and triaging of patients Facilitate communication Better

12、 facilities for service between visits More flexibility internally (diversified staff skills and training) and externally (referring doctors pick what they want) Can be as good as an excellent doctor and can serve more people The Power of Computer The Under Water Volcano Theory of GDM Ross GP et al

13、Diabet Med ; 13(8) : 748-52 Ethnic Susceptibility to GDM is a Function of Ethnic Difference in Age of Onset of Type 2 Diabetes Long-term Efficacy Of Metformin Treatment In Non-obese Individuals With Type 2 Diabetes Ong CR et al ; Diabetes Care 2006 ; 29(11) : 2361-4 Metabolic Syndrome in Type 1 Diab

14、etes McGill M et al : J Diabetes Complications 2008 ; 22(1) : 18-23 Molyneaux L et al : Diabetes Obesity and Metabolism 2004 ; 6 : 187-94 Strong Family History Predicts A Younger Age Of Onset For Subjects Diagnosed With Type 2 Diabetes A Transplant of Diabetes Centre to Rural Area Overseas Collabora

15、tions Fiji and KirabatiChina Hoskins PL et al : Diabetes Res Clin Pract 1987 ; 3(5) ; 257-67 Hoskins PL et al : diabetes Res Clin Pract 1987 ; 3(5) : 257-67 Liu DP et al Diabetes Res Clin Pract 2002 ; 56(2) ; 125-31 Wong, J et al : Journal of Diabetes and Complications 2008 ; 22 : 389-394 Training a

16、nd Exchange Programs National and International Clinical Research and Basic Science Research Brooks B et al : Diabetes Care 1999 ; 22(10) : 1722-7 Brooks B et al : Diabet Med 2001 : 18(5) : 374-80 Biomedical Research on Diabetic Complications Brooks B et al : J Clin Endocrinol Metab 1994 ; 79(6) : 1

17、681-5 Brooks BA et al : Diabetes Obes Metab 2008 ; 10(9) ; 739-46 Skin Biopsy to Assess Small Fibre Diabetic Neuropathy Sorensen L et al : Diabetes Care 2006 ; 22(3) : 261-5 Magnetic Resonance Spectroscopy in the Study of Diabetic Neuropathic Pain D. mI Cho Cr/PCr Gluc Glx/GABA B. C. NAA Sorensen L

18、et al : Diabetes Care 2008 ; 31(5) : 980-1 Relationship Between Age of Diabetes Onset and Mitochondrial DNA Content r=0.7:p=0.0002 r=-0.04:p=0.8 No comps Comps Wong J et al Diabetologia 2009 ; 52(9) : 1953-61 Wound Fluid MMP-9 and TIMP-1 Levels Predict Poor Wound Healing Liu Y:- Diabetes Care 2009 ;

19、 32(1) : 117-9 MMP-9 MMP-9 (g/ml) * * Ratio of MMP-9/TIMP-1 MMP-9/TIMP-1 (x100) * * * p0.05, * p0.01 different from healed within 12 weeks pro-MMP-9 act-MMP-9 Healed Unhealed Healed Unhealed pro-MMP-9/TIMP-1 act-MMP-9/TIMP-1 Xu, L et al Diabetes Care 2007;30(2):378-80 The Relationship of Monocyte Su

20、rface Markers with Diabetes and Retinopathy Min D et al : American Diabetes Association Meeting 2010 Research in a Multi-disciplinary Setting : Less linear than thematic The Interactive Multi-disciplinaryTeam NurseDietitian Doctor DoctorNurse Dietitian What is an Interactive Team ? Weekly Training S

21、essions The Nurses and Other Allied Health Professionals A wider horizon On the job training according to ambition and skills Better rewarded More demanding (The Nuremberg Principle) The seven most senior nurses have worked at the Diabetes Centre for a total of 160 years Professional Development and

22、 Achievements Allied health professionals were 1st author in more than 70 publications in international peer reviewed journals 3 PhD, 4 MSc, 1 MPH Two employees of the month (Information Technology and High Risk Foot Clinic) 1 statistician to an international peer review journal Lilly Award (The Uns

23、ung Heroes) Best High Risk Foot Podiatrist (NSW) Award Chairperson of the NSW Health Telemedicine Committee The first two Nurse Practitioners in diabetes in NSW 3 Associate Professors 1 IDF Senior Vice-President 2 Board Members of JDRF Other Grants and Awards 12 babies ! The Doctors Take responsibility Contribute to leadership and vision Training of staff Do the things that allied health profess