1. Journal Club 埼玉医科大学 総合医療センター 内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田 昌文 Matsuda, Masafumi 2015 年 11 月 5 日 8:30-8:55 ８階 医局 Sussman JB, Kerr EA, Saini SD, Holleman RG, Klamerus ML, Min LC, Vijan S, Hofer TP. Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus. JAMA Intern Med. 2015 Oct 26:1-8. doi: 10.1001/jamainternmed.2015.5110. Martin ET, Kaye KS, Knott C, Nguyen H, Santarossa M, Evans R, Bertran E, Jaber L. Diabetes and Risk of Surgical Site Infection: A Systematic Review and Meta-analysis. Infect Control Hosp Epidemiol. 2015 Oct 27:1-12.

2. 1 Department of Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan 2 Department of Internal Medicine, University of Michigan Medical School, Ann Arbor 3 Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor JAMA Intern Med. Published online October 26, 2015. doi:10.1001/jamainternmed.2015.5110

3. Importance Older patients with diabetes mellitus receiving medical treatment whose blood pressure (BP) or blood glucose level are potentially dangerously low are rarely deintensified. Given the established risks of low blood pressure and blood glucose, this is a major opportunity to decrease medication harm. Objective To examine the rate of BP- and blood glucose–lowering medicine deintensification among older patients with type 1 or 2 diabetes mellitus who potentially receive overtreatment.

4. Design, Setting, and Participants Retrospective cohort study conducted using data from the US Veterans Health Administration. Participants included 211 667 patients older than 70 years with diabetes mellitus who were receiving active treatment (defined as BP-lowering medications other than angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or glucose-lowering medications other than metformin hydrochloride) from January 1 to December 31, 2012. Data analysis was performed December 10, 2013, to July 20, 2015. Exposures Participants were eligible for deintensification of treatment if they had low BP or a low hemoglobin A1c (HbA1c) level in their last measurement in 2012. We defined very low BP as less than 120/65 mm Hg, moderately low as systolic BP of 120 to 129 mm Hg or diastolic BP (DBP) less than 65 mm Hg, very low HbA1c as less than 6.0%, and moderately low HbA1c as 6.0% to 6.4%. All other values were not considered low. Main Outcomes and Measures Medication deintensification, defined as discontinuation or dosage decrease within 6 months after the index measurement.

8. Figure 3. Predicted Probability of Deintensification by Baseline Blood Pressure (BP) and Hemoglobin A1c (HbA1c) Levels and Life Expectancy Error bars indicate 95%CI.

9. Figure 3. Predicted Probability of Deintensification by Baseline Blood Pressure (BP) and Hemoglobin A1c (HbA1c) Levels and Life Expectancy Error bars indicate 95%CI.

10. Solid line with arrowhead indicates standard vascular risk control strategy. Dashed lines with arrowheads indicate possible vascular risk control strategies for robust and vulnerable patients, with question marks pointing out the need for a choice. Gray box presents the proposed approach for vulnerable individuals. HbA1c indicates hemoglobin A1c; RCTs, randomized clinical trials; SBP, systolic blood pressure; and T2DM, type 2 diabetes mellitus. To convert HbA1c to a proportion of total hemoglobin, multiply by 0.01. JAMA Intern Med. Published online October 26, 2015. doi:10.1001/jamainternmed.2015.5941

11. Results The actively treated BP cohort included 211667 participants, more than half of whom had moderately or very low BP levels. Of 104486 patients with BP levels that were not low, treatment in 15.1% was deintensified. Of 25955 patients with moderately low BP levels, treatment in 16.0% was deintensified. Among 81226 patients with very low BP levels, 18.8% underwent BP medication deintensification. Of patients with very low BP levels whose treatment was not deintensified, only 0.2% had a follow-up BP measurement that was elevated (BP ≥140/90 mm Hg). The actively treated HbA1c cohort included 179991 participants. Of 143305 patients with HbA1c levels that were not low, treatment in 17.5% was deintensified. Of 23769 patients with moderately low HbA1c levels, treatment in 20.9% was deintensified. Among 12917 patients with very low HbA1c levels, 27.0% underwent medication deintensification. Of patients with very low HbA1c levels whose treatment was not deintensified, fewer than 0.8% had a follow-up HbA1c measurement that was elevated (≥7.5%).

12. Conclusions and Relevance Among older patients whose treatment resulted in very low levels of HbA1c or BP, 27% or fewer underwent deintensification, representing a lost opportunity to reduce overtreatment. Low HbA1c or BP values or low life expectancy had little association with deintensification events. Practice guidelines and performance measures should place more focus on reducing overtreatment through deintensification.

13. Message 血糖の強化療法を緩和するという論文がついに出 てきた！ “Disintensification!” そのうち糖尿病の専門家の言うことはほとんど一 般開業医には受け入れられなくなるかもしれない。

15. 1 Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan 2 Division of Infectious Diseases, Wayne State University and Detroit Medical Center, Detroit, Michigan 3 Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan Infect Control Hosp Epidemiol. 2015 Oct 27:1-12. DOI: http://dx.doi.org/10.1017/ice.2015.249

16. OBJECTIVE To determine the independent association between diabetes and surgical site infection (SSI) across multiple surgical procedures.

17. DESIGN Systematic review and meta-analysis. METHODS Studies indexed in PubMed published between December 1985 and through July 2015 were identified through the search terms “risk factors” or “glucose” and “surgical site infection.” A total of 3,631 abstracts were identified through the initial search terms. Full texts were reviewed for 522 articles. Of these, 94 articles met the criteria for inclusion. Standardized data collection forms were used to extract study-specific estimates for diabetes, blood glucose levels, and body mass index (BMI). A random-effects meta-analysis was used to generate pooled estimates, and meta-regression was used to evaluate specific hypothesized sources of heterogeneity.

20. figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.

28. figure 3. Meta-analysis of pre-operative hyperglycemia and surgical site infection.

29. figure 4. Meta-analysis of post-operative hyperglycemia and surgical site infection.

30. RESULTS The primary outcome was SSI, as defined by the Centers for Disease Control and Prevention surveillance criteria. The overall effect size for the association between diabetes and SSI was odds ratio (OR)=1.53 (95% predictive interval [PI], 1.11–2.12; I2, 57.2%). SSI class, study design, or patient BMI did not significantly impact study results in a meta-regression model. The association was higher for cardiac surgery 2.03 (95% PI, 1.13–4.05) compared with surgeries of other types (P=.001).

31. CONCLUSIONS These results support the consideration of diabetes as an independent risk factor for SSIs for multiple surgical procedure types. Continued efforts are needed to improve surgical outcomes for diabetic patients.

32. Message 糖尿病で術後感染が増加することが再確認された。 当然だと感じるが しかし血糖をよくしたからと言ってよくなるかは 不明であるが。