ARTIKELEN OVER ACROMEGALIE
Diabetes Mellitus Following Hypophysectomy in Previously Normoglycaemic Patients with Acromegaly
Growth hormone has a biphasic effect, that is to say at low levels, it has an anti-insulin effect whereas moderate and high levels, it exhibits an insulin-like effect (1,2,3). In the event of chronic exposure, the diabetogenic effects of growth hormone appear as reduced peripheral glucose uptake, a drop in adipocyte response to insulin, and increased blood glucose output by hepatocytes. Certain growth hormone by-products and metabolites also exert an influence on glucose metabolism, such as hGH1-43, which has an insulin-like hypoglycaemic effect, andhGH172-191, which has diabetogenic effects(5). Impaired glucose tolerance is seen in 60-70 percent of patients with acromegaly, and in 10-20 percent of patients who are suitably predisposed, overt diabetes develops (1,2,3,4). Following successful treatment of acromegaly, one expects growth hormone levels, as well as the response to glucose tolerance testing, to return to normal. In rare cases, however, through an unknown mechanism, patients have developed diabetes mellitus following treatment for acromegaly, whereas these patients had been normoglycaemic prior to treatment. This article introduces five such cases.
76 Nederlands Tijdschrift voor Diabetologie, Jrg. 1, nr 2 • November 2003
Iemand met diabetes moet en kan zelf de dagelijkse behandeling van de ziekte (indien mogelijk) uitvoeren.
Deze dagelijkse zorg voor diabetes vraagt veel en vereist adequate kennis, vaardigheden, doorzettingsvermogen, aanmoediging en motivatie. De uiteindelijke uitkomsten van diabeteszorg worden grotendeels bepaald door deze dagelijkse beslissingen en handelingen. De mens met diabetes is daarmee hoofdbehandelaar en direct verantwoordelijke voor de dagelijkse beslissingen in behandeling. Zonder educatie is geen goede diabeteszorg mogelijk.
DIABETES MELLITUS 2
Pharmaceutical care in diabetes: quantifying and evaluating community pharmacy’s support to patients performing blood glucose self-monitoring Proefschrift van Michiel Storimans
18 januari 2006 Universiteit Utrecht
The high prevalence and incidence of diabetes mellitus and its complications have led to a serious growth in the demand for diabetes-related health care in the Netherlands. Since self-management by the patient is a cornerstone of the treatment plan, self-management education has become an important part of diabetes care. One aspect of self-management education is self-monitoring of blood glucose (SMBG). SMBG is a technique that enables patients to monitor and react to changes in their blood glucose levels, allowing them to integrate their diabetes into the life style they prefer. Furthermore, it allows physicians to gather data for clinical decision-making.
However, SMBG is a relatively complex process that requires specialised equipment, counselling and follow-up. National and international pharmacy practice guidelines advocate that one of the community pharmacists\\\' roles in diabetes care is to support patients with SMBG. Since most patients regularly visit their pharmacy, pharmacies are ideally placed to support patients managing their own diabetes. Still, to what extent these guidelines are actually implemented in daily routine is unknown.
The aim of this thesis is to assess the level and the variation in the services that Dutch community pharmacies provide to patients performing blood glucose self-monitoring. Furthermore, it describes the key determinants of these self-monitoring services.
The studies reveal a significant variation in the services provided by community pharmacies. This variation is the result of many factors: differences in patient characteristics between community pharmacies, pharmacy-related determinants (for example the pharmacy team\\\'s competence and the pharmacist\\\'s perceptions of SMBG) and supra-pharmacy determinants (regional differences in for example collaboration, competition and remuneration). Although these determinants have received much attention in medical care and quality assessment, few comparable studies have been performed in pharmacy practice research, especially on diabetes care.
Based on the results of this thesis, changes in the implementation strategy of community pharmacy services are recommended. Tailor-made implementation plans and coaching of community pharmacists may be needed, since the presence of key determinants on many different levels requires an intervention must attuned to fit the local situation.
As long as community pharmacies are not reimbursed for self-monitoring services, most pharmacists will continue to prefer providing services in which they experience less competition, as for example medication surveillance and patient counselling on inhalers. At present, this makes the supra-pharmacy determinants of SMBG the most relevant barrier that limit the adoption of self-monitoring services.
Finally, this thesis signals the need for more research into the process of community pharmacy services and its \\\'building blocks\\\'. A careful consideration of the definition of the care process is required in pharmacy practice research. Furthermore, knowledge of the association between the structure of care and the process of care is essential in developing quality indicators and quality improvement.
DIABETES MELLITUS OMVANG VAN HET PROBLEEM RIVM
Hoe vaak komt diabetes mellitus voor en hoeveel mensen sterven eraan?
\\\'JE GAAT HET PAS ZIEN ALS JE HET DOOR HEBT:MULTIMORBIDITEIT IN DE HUISARTSENPRAKTIJK\\\'.
Rede uitgesproken bij de aanvaarding van het ambt van bijzonder hoogleraar Multimorbiditeit in de huisartsenpraktijk vanwege het NIVEL (Nederlands Instituut voor onderzoek van de gezondheidszorg) aan de faculteit der Geneeskunde van de Vrije Universiteit / VU Medisch Centrum op 11 oktober 2006.
door Prof. Dr. F.G. Schellevis