Epidemiology and Control of diabetes - tuberculosis comorbidity in Eswatini: protocol for the prospective study of tuberculosis patients on predictive factors, treatment outcomes and patient management practices

INTRODUCTION

Previous studies indicate people with diabetes mellitus (DM) may have varying treatment outcomes when receiving treatment for tuberculosis (TB) and that TB infection or its treatment may predispose them to develop an abnormal blood glucose or type 2 DM. This has implications for Eswatini which is a high TB burden country and with increasing cases of non-communicable diseases including DM. This study will describe the epidemiology of DM-TB comorbidity in a prospective cohort of patients receiving TB treatment and identify best practices for integration of care for non-communicable diseases into TB services in Eswatini.

METHODS AND ANALYSIS

This study will employ a mixed-methods approach. Data from a prospective cohort of newly enrolled patients with TB at 12 health facilities from 1 June 2022 to 30 September 2022, and followed up to 30 April 2023, will be used. For the qualitative, key informants who provide TB services at the health facilities will be interviewed. Quantitative data from patients will be analysed descriptively and by tests of association and multivariate modelling. Key informant interviews from healthcare workers will be analysed using content analysis.

ETHICS AND DISSEMINATION

This research has been approved by the Eswatini Health and Human Research Review Board and participant confidentiality will be maintained. COVID-19 safety measures to reduce the risk of infection or transmission by researchers and participants have been instituted. Key programmatic findings and how they can impact healthcare delivery and access will be presented to the specific programme in the Eswatini Ministry of Health and other relevant stakeholders.

Acupuncture for patients with type 2 diabetes mellitus with dry eye: protocol for a systematic review and meta-analysis

INTRODUCTION

The global incidence of patients with type 2 diabetes mellitus (T2DM) with dry eye is increasing annually, which imposes additional healthcare costs and financial burden on families and societies. In clinical practice, artificial tears are often used for symptomatic treatment, but these can only relieve the symptoms of discomfort. Acupuncture is a widely used alternative therapy. Indeed, randomised trials have found that acupuncture confers a definite therapeutic effect on patients with T2DM with dry eye. However, systematic reviews on the effectiveness and safety of acupuncture are lacking, therefore this systematic review aims to evaluate the effectiveness and safety of acupuncture for T2DM with dry eye.

METHODS AND ANALYSIS

Four English databases (PubMed, Cochrane Library, Embase and Ovid), three Chinese databases (China National Knowledge Infrastructure, Wanfang, Chonqing VIP Information), three Japanese databases (Japan Science, Technology Agency and Japan Medical Abstracts Society) and three Korean databases (Korean Medical database, Oriental Medicine Advanced Searching Integrated System and Research Information Service System) will be searched for reports published between 1 January 2007 and 1 October 2021. Only randomised controlled trials will be included, and language or publication dates will not be restricted. Two researchers will independently extract, manage and analyse data. The primary outcomes will include Schirmer's I test, breakup time, corneal fluorescein staining and ocular surface disease index scores. Secondary results will include visual analogue scale scores for ocular symptoms and any adverse events related to acupuncture. We will use Review Manager V.5.4 for the meta-analysis. The risk of bias will be independently assessed using Cochrane's 'risk of bias' tool.

ETHICS AND DISSEMINATION

Ethical approval will not be required since raw data will not be collected or generated. Our findings will be disseminated through peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021271891.

Protocol for a feasibility study and process evaluation of a psychosocially modelled diabetes education programme for young people with type 1 diabetes: the Youth Empowerment Skills (YES) programme

INTRODUCTION

Adolescence is a challenging period for young people with type 1 diabetes, associated with worsening glycaemia and care disengagement. Educational interventions in this period tend to focus on diabetes-specific skills, with less emphasis on the psychosocial challenges associated with diabetes experienced by young people. To address this limitation, we codesigned with young people a psychosocially modelled programme of diabetes education, named 'Youth Empowerment Skills' (YES). The programme aims to facilitate a positive adaptation to life with diabetes and engagement with diabetes care through peer-based learning, immersive simulations and support from an outreach youth worker. Here, we present a protocol for a feasibility study of the YES programme.

METHODS AND ANALYSIS

The study was designed following the Medical Research Council Complex Intervention Evaluation Framework to: test the feasibility (acceptance, implementability, recruitment and completion) of the YES programme; and estimate its efficacy in relation to metabolic and psychosocial outcomes. The study will take place in diabetes centres serving socioculturally diverse populations. We will conduct a feasibility randomised controlled trial (waiting-list design) with integrated process evaluation. Fifty young people with type 1 diabetes (aged 14-19 years) will be randomly allocated to either the YES intervention or a waiting-list control. Randomisation acceptability will be assessed with provision for a preference allocation. Outcomes will be evaluated at 6 months, at which point the waiting list participants will be exposed to the YES programme with further follow-up to 12 months. A simultaneous process evaluation will use a mixed-methods approach collecting qualitative and quantitative data. Study findings will be used to optimise the intervention components, outcome measures and recruitment methods to inform a subsequent definitive trial.

ETHICS AND DISSEMINATION

The protocol has ethical approval from the UK Health Research Authority (approval IRAS project ID: 279877). Findings will be disseminated in multiple formats for lay and professional audiences.

PROTOCOL DATE AND VERSION

7 April 2021, V.1.1.

TRIAL REGISTRATION NUMBER

NCT04670198.

Study protocol for an epidemiological study 'Multimorbidity - identifying the most burdensome patterns, risk factors and potentials to reduce future burden (MOLTO)' based on the Finnish health examination surveys and the ongoing register-based follow-up

INTRODUCTION

Multimorbidity, defined as the co-occurrence of two or more long-term medical conditions, is an increasing public health concern worldwide causing enormous burden to individuals, healthcare systems and societies. The most effective way of decreasing the burden caused by multimorbidity is to find tools for its successful prevention but gaps in research evidence limit capacities to develop prevention strategies. The aim of the MOLTO study (Multimorbidity - identifying the most burdensome patterns, risk factors and potentials to reduce future burden) is to provide novel evidence required for cost-effective prevention of multimorbidity by defining the multimorbidity patterns causing the greatest burden at the population level, by examining their risk and protective factors and by estimating the potentials to reduce the future burden.

METHODS AND ANALYSIS

The MOLTO study is based on the data from the Finnish population-based cross-sectional (FINRISK 2002-2012, FinHealth 2017 the Migrant Health and Well-being Study 2010-2012) and longitudinal (Health 2000/2011) health examination surveys with individual-level link to administrative health registers, allowing register-based follow-up for the study participants. Both cross-sectional and longitudinal study designs will be used. Multimorbidity patterns will be defined using latent class analysis. The burden caused by multimorbidity as well as risk and protective factors for multimorbidity will be analysed by survival analysis methods such as Cox proportional hazards and Poisson regression models.

ETHICS AND DISSEMINATION

The survey data have been collected following the legislation at the time of the survey. The ethics committee of the Hospital District of Helsinki and Uusimaa has approved the data collection and register linkages for each survey. The results will be published as peer-reviewed scientific publications.

Implementation of the Diabetes Community Exercise and Education Programme (DCEP) for the management of type 2 diabetes: qualitative process evaluation

OBJECTIVES

To examine context-specific delivery factors, facilitators and barriers to implementation of the Diabetes Community Exercise and Education Programme (DCEP) for adults with type 2 diabetes (T2D) using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework.

DESIGN

A qualitative evaluation embedded within the DCEP pragmatic randomised controlled trial. Data collected via focus groups and interviews and analysed thematically.

SETTING

Community-based in two cities (Dunedin and Invercargill) in the lower south island of New Zealand.

PARTICIPANTS

Seventeen adults diagnosed with T2D attending DCEP and 14 healthcare professionals involved in DCEP delivery.

INTERVENTION

DCEP is a twice weekly session of exercise and education over 12 weeks, followed by a twice weekly ongoing exercise class.

RESULTS

While our reach target was met (sample size, ethnic representation), the randomisation process potentially deterred Māori and Pasifika from participating. The reach of DCEP may be extended through the use of several strategies: promotion of self-referral, primary healthcare organisation ownership and community champions. DCEP was considered effective based on perceived benefit. The social and welcoming environment created relationships and connections. People felt comfortable attending DCEP and empowered to learn. Key to implementation and adoption was the building of trusting relationships with local health providers and communities. This takes time and care and cannot be rushed. Training of staff and optimising communication needed further attention. To maintain DCEP, delivery close to where people live and a generic approach catering for people with multiple chronic conditions may be required.

CONCLUSIONS

For success, lifestyle programmes such as DCEP, need time and diligence to build and maintain networks and trust. Beyond frontline delivery staff and target populations, relationships should extend to local healthcare organisations and communities. Access and ongoing attendance are enabled by healthcare professionals practicing in a nuanced person-centred manner; this, plus high staff turnover, necessitates ongoing training.

TRIAL REGISTRATION NUMBER

ACTRN12617001624370.

Real-world evidence on the use of a fixed-ratio combination of insulin glargine and lixisenatide (iGlarLixi) in people with suboptimally controlled type 2 diabetes in Romania: a prospective cohort study (STAR.Ro)

OBJECTIVES

To assess the effectiveness and safety of insulin glargine and lixisenatide (iGlarLixi) fixed-ratio combination on a cohort of Romanian adults with type 2 diabetes (T2D).

DESIGN

Open-label, 24-week, prospective cohort study.

SETTING

65 secondary care diabetes centres in Romania.

PARTICIPANTS

The study included 901 adults with T2D suboptimally controlled with previous oral antidiabetic drugs (OADs)±basal insulin (BI) who initiated treatment with iGlarLixi upon the decision of the investigator. Major exclusion criteria were iGlarLixi contraindications and refusal to participate. 876 subjects received at least one dose of iGlarLixi (intention-to-treat/safety population).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was change in glycated haemoglobin (HbA1c) from baseline to week 24 in the modified intention-to-treat population (study participants with HbA1c available at baseline and week 24). Secondary efficacy outcomes were percentage of participants reaching HbA1c targets and change in fasting plasma glucose (FPG).

RESULTS

Mean baseline HbA1c was 9.2% (SD 1.4) and FPG was 10.8 mmol/L (2.9). Mean HbA1c change was -1.3% (95% CI: -1.4% to -1.2%, p<0.0001) at week 24. HbA1c levels ≤6.5%, <7% and<7.5% at week 24 were achieved by 72 (8.9%), 183 (22.6%) and 342 (42.3%) participants, respectively. Mean FPG change was -3.1 mmol/L (95% CI: -3.3 to -2.8, p<0.001) at week 24. Mean body weight change was -1.6 kg (95% CI: -1.9 to -1.3, p<0.001) at 24 weeks. Mean iGlarLixi dose increased from 19.5 U (SD 7.7) and 30.1 U (10.0) to 30.2 U (8.9) (ratio 2/1 pen) and 45.0 U (11.6) (ratio 3/1 pen). Adverse events (AEs) were reported by 43 (4.9%) participants (18 (2.1%) gastrointestinal) with 4 (0.5%) reporting serious AEs. 13 (1.5%) participants reported at least one event of symptomatic hypoglycaemia, with one episode of severe hypoglycaemia reported.

CONCLUSIONS

In a real-world setting, 24-week treatment with iGlarLixi provided a significant reduction of HbA1c with body weight loss and low hypoglycaemia risk in T2D suboptimally controlled with OADs±BI treatment.

Epidemiological and clinical characteristics of patients hospitalised with COVID-19 in Kenya: a multicentre cohort study

OBJECTIVES

To assess outcomes of patients admitted to hospital with COVID-19 and to determine the predictors of mortality.

SETTING

This study was conducted in six facilities, which included both government and privately run secondary and tertiary level facilities in the central and coastal regions of Kenya.

PARTICIPANTS

We enrolled 787 reverse transcriptase-PCR-confirmed SARS-CoV2-infected persons. Patients whose records could not be accessed were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was COVID-19-related death. We used Cox proportional hazards regressions to determine factors related to in-hospital mortality.

RESULTS

Data from patients with 787 COVID-19 were available. The median age was 43 years (IQR 30-53), with 505 (64%) being men. At admission, 455 (58%) were symptomatic with an additional 63 (9%) developing clinical symptoms during hospitalisation. The most common symptoms were cough (337, 43%), loss of taste or smell (279, 35%) and fever (126, 16%). Comorbidities were reported in 340 (43%), with cardiovascular disease, diabetes and HIV documented in 130 (17%), 116 (15%), 53 (7%), respectively. 90 (11%) were admitted to the Intensive Care Unit (ICU) for a mean of 11 days, 52 (7%) were ventilated with a mean of 10 days, 107 (14%) died. The risk of death increased with age (HR 1.57 (95% CI 1.13 to 2.19)) for persons >60 years compared with those <60 years old; having comorbidities (HR 2.34 (1.68 to 3.25)) and among men (HR 1.76 (1.27 to 2.44)) compared with women. Elevated white cell count and aspartate aminotransferase were associated with higher risk of death.

CONCLUSIONS

The risk of death from COVID-19 is high among older patients, those with comorbidities and among men. Clinical parameters including patient clinical signs, haematology and liver function tests were associated with risk of death and may guide stratification of high-risk patients.

Cohort profile: The Xinjiang Multiethnic Cohort (XMC) study

PURPOSE

To investigate the potential causal link between heredity, geographical environment, diet and other lifestyle factors with long-term health consequences, we established the Xinjiang Multiethnic Cohort Study (XMC), the first large-scale prospective cohort in Xinjiang, China.

PARTICIPANTS

XMC commenced in 2018 and enrolled participants from three study sites (Urumqi, Hotan and Ili) in Xinjiang, China. Data collected include standard baseline questionnaire, physical measurement, biological specimen. In addition, about one-third of participants were assessed habitual diet by a more detailed semiquantitative food frequency questionnaire which included 127 foods items at baseline FINDINGS TO DATE: Finally, a total of 30 949 participants, with 32.37% from Urumqi, 41.75% from Hotan, and 25.88% from Ili were recruited in XMC. The average age of participants was 56.21 years for men, and 54.75 years for women. More than 60% of participants in all three survey sites reported an average consumption of fruit and vegetable three or more times per week. In Hotan and Ili, the staple food was wheaten food, whereas, in Urumqi, rice and wheaten food was the food staples. Consumption of white meat, such as fish and poultry, was lower in the three survey locations. Based on self-reported disease from study participants, the five most common chronic diseases among participants across all three survey locations were dyslipidaemia, hypertension, cholecystitis, diabetes, ischaemic heart disease.

FUTURE PLANS

First, we will collect all health-related records of the study participants in January each year for the previous year. Second, 10% of subjects were randomly selected for telephone follow-up in the final year of cohort building. Finally, as planned, we will revisit the study subjects on site every 2-3 years. Again, we will conduct face-to-face questionnaires and collect biological specimens such as blood and urine from the study subjects.

Impact of trends and gender disparity in obesity on future type 2 diabetes in Turkey: a mathematical modelling analysis

BACKGROUND

Using a previously developed and validated mathematical model, we predicted future prevalence of type 2 diabetes mellitus (T2DM) and major modifiable risk factors (obesity, physical inactivity and smoking) stratified by age and sex in Turkey up to the year 2050.

METHODS

Our deterministic compartmental model fitted nationally representative demographic and risk factor data simultaneously for Turkish adults (aged 20-79) between 1997 and 2017, then estimated future trends. Our novel approach explored the impact of future obesity trends on these projections, specifically modelling (1) a gradual fall in obesity in women after the year 2020 until it equalled the age-specific levels seen in men and (2) cessation of the rise in obesity after 2020.

RESULTS

T2DM prevalence is projected to rise from an estimated 14.0% (95% uncertainty interval (UI) 12.8% to 16.0%) in 2020 to 18.4% (95% UI 16.9% to 20.9%) by 2050; 19.7% in women and 17.2% in men by 2050; reflecting high levels of obesity (39.7% for women and 22.0% for men in 2050). Overall, T2DM prevalence could be reduced by about 4% if obesity stopped rising after 2020 or by 12% (22% in women) if obesity prevalence among women could be lowered to equal that of men. The higher age-specific obesity prevalence among women resulted in 2 076 040 additional women developing T2DM by the year 2050.

CONCLUSION

T2DM is common in Turkey and will remain so. Interventions and policies targeting the high burden of obesity (and low physical activity levels), particularly in women, could significantly impact future disease burdens.

Randomised controlled trials on prevention, diagnosis and treatment of diabetes in African countries: a systematic review

OBJECTIVES

The epidemiological transition from infectious to chronic diseases leads to novel challenges in African health systems. The prevalence of diabetes mellitus (DM) is increasing dramatically. Undiagnosed and undertreated DM leads to numerous complications including end-organ damage and death. Our objectives were to collect the best locally generated evidence on DM interventions, identify knowledge gaps and determine underexplored research areas.

DESIGN

A systematic review and meta-analysis of randomised controlled trials.

PARTICIPANTS AND SETTING

African patients in primary, secondary and tertiary prevention, diagnosis and treatment DM type 1 (DM1), type 2 (DM2) and gestational DM (GDM).

OUTCOME

All-cause mortality, glycaemic control, complications, quality of life, hospital admission, treatment adherence and costs.

DATA SOURCES

Articles published in MEDLINE Ovid, CENTRAL, CINAHL, African Journals Online and African Index Medicus and the International Clinical Trials Registry Platform in English language without time restrictions. The systematic search was last updated in October 2020.

RESULTS

Out of 3736 identified publications, we included 60 eligible studies conducted in 15 countries, 75% were conducted in urban healthcare settings, including 10 112 participants. We included 8 studies on DM1, 6 on GDM, 2 on pre-DM, 37 on mainly DM2 including 7 on DM-related complications. The design of the studied intervention was heterogeneous with a focus on educational strategies. The other studies investigated the efficacy of nutritional strategies including food supplementations, pharmacological strategies and strategies to enhance physical activity. Seven studies included interventions on DM-related complications.

CONCLUSIONS

Research activities increased in recent years, but available evidence is still not representative for all African countries. There is a big lack of evidence in primary healthcare and rural settings, implementation research, pharmacological interventions, especially in poorer countries. Nevertheless, the identified studies offer a variety of effective interventions that can inform medical care and future research.

PROSPERO REGISTRATION NUMBER

CRD42019122785.

Association between metformin use and the risk of age-related macular degeneration in patients with type 2 diabetes: a retrospective study

OBJECTIVES

To investigate the effect of metformin on the decreased risk of developing age-related macular degeneration (AMD) in patients with type 2 diabetes mellitus (T2DM) for ≥10 years.

DESIGN

A retrospective study.

PARTICIPANTS

Patients aged ≥50 with a diagnosis of T2DM no less than 10 years were included.

METHODS

Variables predisposing to AMD were reviewed; the potential confounders related to T2DM or AMD were selected from literature records; AMD and diabetic retinopathy (DR) were diagnosed by funduscopy, optical coherence tomography and/or fluorescein angiography. The subgroup analysis was performed in early and late AMD. The protective effect of metformin was evaluated in duration-response and dose-response patterns.

RESULTS

A total of 324 patients (115 metformin non-users and 209 users) were included in the final analysis. AMD was observed in 15.8% of metformin users and 45.2% of metformin non-users (p<0.0001). The ORs for any AMD, early AMD and late AMD present in patients with DR were 0.06 (0.02-0.20), 0.03 (0.00-0.20) and 0.17 (0.04-0.75). The serum high-density lipoprotein level was positively associated with the late AMD risk (p=0.0054). When analysed by the tertiles of cumulative duration, a similarly reduced risk was observed for the second (5-9 years) (OR: 0.24, 95% CI: 0.08 to 0.75) and third tertiles (≥10 years) (OR: 0.22, 95% CI: 0.09 to 0.52) compared with the first tertile (≤4 years).

CONCLUSION

Among patients with T2DM for ≥10 years, metformin users were less likely to develop any AMD and early AMD than non-users; however, the late AMD was not significantly associated with the use of metformin. Also, AMD was less prevalent in patients with DR. The prolonged metformin treatment with a high cumulative dose enhanced the protective effect against AMD. Metformin significantly reduces the AMD risk when the cumulative duration is >5 years.

Acceptability and feasibility of an acceptance and commitment therapy-based guided self-help intervention for weight loss maintenance in adults who have previously completed a behavioural weight loss programme: the SWiM feasibility study protocol

INTRODUCTION

The cost-effectiveness and long-term health impact of behavioural weight management programmes depends on post-treatment weight-loss maintenance. Growing evidence suggests that interventions using acceptance and commitment therapy (ACT) could improve long-term weight management. We developed an ACT-based, guided self-help intervention to support adults who have recently completed a behavioural weight loss programme. This study will assess the feasibility and acceptability of this type of intervention and findings will inform the development of a full-scale trial.

METHODS AND ANALYSIS

This is a pragmatic, randomised, single-blind, parallel group, two-arm, feasibility study with an embedded process evaluation. We will recruit and randomise 60 adults who have recently completed a behavioural weight loss programme to the ACT-based intervention or standard care, using a computer-generated sequence with 2:1 allocation stratified by diabetes status and sex. Baseline and 6-month measurements will be completed using online questionnaires. Qualitative interviews will be conducted with a subsample of participants and coaches about their experiences at 3 (mid-intervention) and 6 (postintervention) months. Feasibility and acceptability of the intervention, and a full-scale trial will be assessed using a number of outcomes, including adherence to, and engagement with the intervention, recruitment and retention rates, proportion of missing data for each outcome measure, participants' experiences of the intervention and study, and coaches' experiences of delivering intervention support. Quantitative and qualitative findings will be integrated and summarised to contribute to the interpretation of the main feasibility evaluation findings. Value of information methods will be used to estimate the decision uncertainty associated with the intervention's cost-effectiveness and determine the value of a definitive trial.

ETHICS AND DISSEMINATION

Ethical approval was received from Cambridge South Research Ethics Committee on 15/03/2021 (21/EE/0024). This protocol (V.2) was approved on 19 April 2021. Findings will be published in peer-reviewed scientific journals and communicated to other stakeholders as appropriate.

TRIAL REGISTRATION NUMBER

ISRCTN12685964.

Comparing effects of obesity treatment with very low energy diet and bariatric surgery after 2 years: a prospective cohort study

OBJECTIVES

To compare long-term effects and complications of medical treatment (MT) of obesity including very low energy diet with bariatric surgery.

DESIGN AND SETTING

This prospective study conducted in a clinical setting recruited individuals with body mass index (BMI) ≥35 kg/m² referred for obesity treatment. Demographic and anthropometric data, laboratory samples, and questionnaire replies were collected at baseline and 2 years.

PARTICIPANTS AND INTERVENTIONS

971 individuals were recruited 2015-2017. 382 received MT, 388 Roux-en-Y gastric bypass (RYGB) and 201 sleeve gastrectomy (SG).

MAIN OUTCOME MEASURES

Primary outcomes included changes in anthropometric measures, metabolic variables and safety. These were analysed using a linear regression model. A logistic regression model was used to analyse composite variables for treatment success (secondary outcomes). A random forest (RF) model was used to examine the importance of 15 clinical domains as predictors for successful treatment.

RESULTS

Two-year data were available for 667 individuals (68.7%). Regarding primary outcomes, the decrease in excess BMI was 27.5%, 82.5% and 70.3% and proportion achieving a weight of >10% was 45.3%, 99.6% and 95.6% for MT, RYGB and SG, respectively (p<0.001). The groups were comparable regarding levels of vitamins, minerals and haemoglobin or safety measures. Likelihood for success (secondary outcome) was higher in the surgical groups (RYGB: OR 5.3 (95% CI 3.9 to 7.2) vs SG: OR 4.3 ((95% CI 3.0 to 6.2)) in reference to MT. Baseline anthropometry had the strongest predictive value for treatment success, according to the RF model.

CONCLUSIONS

In clinical practice, bariatric surgery by RYGB or SG is most effective, but meaningful weight loss is achievable by MT with strict caloric restriction and stepwise introduction of a normal diet. All treatments showed positive effects on well-being, cardiovascular risk factors, and levels of vitamins and minerals at 2-year follow-up and groups were similar regarding safety measures.

TRIAL REGISTRATION NUMBER

NCT03152617.

Cost-effectiveness of multicomponent interventions in type 2 diabetes mellitus in a cluster randomised controlled trial: the INDICA study

OBJECTIVE

To analyse the cost-effectiveness of multicomponent interventions designed to improve outcomes in type 2 diabetes mellitus (T2DM) in primary care in the Canary Islands, Spain, within the INDICA randomised clinical trial, from the public health system perspective.

DESIGN

An economic evaluation was conducted for the within-trial period (2 years) comparing the four arms of the INDICA study.

SETTING

Primary care in the Canary Islands, Spain.

PARTICIPANTS

2334 patients with T2DM without complications were included.

INTERVENTIONS

Interventions for patients (PTI), for primary care professionals (PFI), for both (combined intervention arm for patients and professionals, CBI) and usual care (UC) as a control group.

OUTCOMES

The main outcome was the incremental cost per quality-adjusted life-years (QALY). Only the intervention and the healthcare costs were included.

ANALYSIS

Multilevel models were used to estimate results, and to measure the size and significance of incremental changes. Missed values were treated by means of multiple imputations procedure.

RESULTS

There were no differences between arms in terms of costs (p=0.093), while some differences were observed in terms of QALYs after 2 years of follow-up (p=0.028). PFI and CBI arms were dominated by the other two arms, PTI and UC. The differences between the PTI and the UC arms were very small in terms of QALYs, but significant in terms of healthcare costs (p=0.045). The total cost of the PTI arm (€2571, 95% CI €2317 to €2826) was lower than the cost in the UC arm (€2750, 95% CI €2506 to €2995), but this difference did not reach statistical significance. Base case estimates of the incremental cost per QALY indicate that the PTI strategy was the cost-effective option.

CONCLUSIONS

The INDICA intervention designed for patients with T2DM and families is likely to be cost-effective from the public healthcare perspective. A cost-effectiveness model should explore this in the long term.

TRIAL REGISTRATION NUMBER

NCT01657227.

Prevalence of metabolic syndrome among the adult population in western China and the association with socioeconomic and individual factors: four cross-sectional studies

OBJECTIVES

This study explored the prevalence of and individual influencing factors for metabolic syndrome (MS) as well as associated socioeconomic factors and regional aggregation.

DESIGN

Four cross-sectional surveys were analysed for trends in MS and associations with socioeconomic and individual factors through multilevel logistic regression analyses. The risk associated with nutrient intake was also assessed through a dietary survey in 2015.

SETTING

From 2010 to 2018, 8-15 counties/districts of West China were included.

PARTICIPANTS

A total of 28 274 adults were included in the prevalence analysis. A total of 23 708 adults were used to analyse the related factors.

RESULTS

The overall prevalence of MS ranged from 21.4% to 27.8% over the 8 years, remaining basically stable within the 95% CI. Our study found that the urbanisation rate and hospital beds per 1000 people were positively associated with MS, and the number of doctors in healthcare institutions per 1000 persons was negatively associated with MS. The ORs for females, people with college education and higher and unmarried or single people were 1.49, 0.67 and 0.51, respectively (p<0.05). The ORs of people who smoked at least 20 cigarettes/day, ate more than 100 g of red meat/day, consumed fruit or vegetable juice and drank carbonated soft drinks less than weekly were 1.10, 1.16, 1.19-1.27 and 0.81-0.84, respectively. The ORs rose with increasing sedentary time and decreased with higher physical activity.

CONCLUSION

The high burden of MS, unreasonable proportions of energy and micronutrient intake and low percentage of high levels of physical activity were the major challenges to public health in western China. Improving the human resources component of medical services, such as the number of doctors, increasing the availability of public sports facilities and E-health tools and improving individual dietary quality and education might help prevent MS.

Use of infrared thermography in medical diagnostics: a scoping review protocol

INTRODUCTION

Thermography offers a non-invasive radiation-free methodology for diagnostic imaging and temperature measurement, but the extent of the current application is unclear, as is the level of evidence for each use case. Moreover, population-based thermographic reference values for diagnostic purposes are nearly unknown. The aim of this scoping review is to identify patient populations and diseases in which thermography is applied, cataloguing of technical and environmental modalities, investigation of the existence of specific reference data and finally exploration of gaps and future tasks.

METHODS AND ANALYSIS

PubMed, Cochrane Database of Systematic Reviews and CENTRAL, Embase, Web of Science and OpenGrey are to be searched using pretested suitable search strategies, with no language restriction, but abstracts should be available in English or German and articles should not have been published before 2000. This limited time frame is due to the rapid technological progress, which makes it necessary to exclude reports based on outdated technology. The literature found will be selected on the basis of previously defined inclusion and exclusion criteria. Subsequently, relevant data will be extracted from the included references into a predesigned table. The selection and extraction process will be conducted by two researchers independently. The report of the results will be according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. The entire review process will follow the Joanna Briggs Institute approach. The scoping review protocol is registered at the Open Science Framework.

ETHICS AND DISSEMINATION

Ethical approval is not required for this work, but ethical medicine also obliges us to carefully consider diagnostic alternatives and compare them with current standards. The dissemination of the results will take place in a variety of ways. First and foremost through publication in an open access journal, but also through conference proceedings. In addition, this scoping review will serve to open up new research foci with regard to thermography.

Validation of type 2 diabetes subgroups by simple clinical parameters: a retrospective cohort study of NHANES data from 1999 to 2014

OBJECTIVES

To verify whether a simplified method based on age, body mass index (BMI) and glycated haemoglobin (HbA1c) is feasible in classifying patients with type 2 diabetes (T2D), and evaluate the predictive ability of subgroups in several health and mortality outcomes.

DESIGN

Retrospective cohort study.

SETTING

The National Health and Nutrition Examination Survey 1999-2014 cycle.

PARTICIPANTS

A total of 1960 participants with diabetes and the age at diagnosis greater than 30.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants with T2D were assigned to previously defined (by Ahlqvist) subgroups based on five variables: age, BMI, HbA1c, homoeostasis model assessment (HOMA) 2 estimates of β-cell function (HOMA2-B), and insulin resistance (HOMA2-IR), and on three variables: age, BMI and HbA1c. The classification performances of the three variables were evaluated based on 10-fold cross validation, with accuracy, precision and recall as evaluation criteria. Outcomes were assessed using logistic regression and Cox regression analysis.

RESULTS

Without HOMA measurements, it is difficult to identify severe insulin-resistant diabetes, but other subgroups can be ideally identified. There is no significant difference between the five variables and the three variables in the ability to predict the prevalence of poor cardiovascular health (CVH), chronic kidney disease, non-alcoholic fatty liver disease and advanced liver fibrosis, and the risk of all-cause, cardiovascular disease and cancer-related mortality (p>0.05), except the prevalence of poor CVH in mild age-related diabetes (p<0.05).

CONCLUSIONS

A simple classification based on age, BMI and HbA1c could be used to identify T2D with several health and mortality risks, which is accessible in most individuals with T2D. Due to its simplicity and practicality, more patients with T2D can benefit from subgroup specific treatment paradigms.

STRategies to manage Emergency ambulance Telephone Callers with sustained High needs: an Evaluation using linked Data (STRETCHED) - a study protocol

INTRODUCTION

UK ambulance services have identified a concern with high users of the 999 service and have set up 'frequent callers' services, ranging from within-service management to cross-sectoral multidisciplinary case management approaches. There is little evidence about how to address the needs of this patient group.

AIM

To evaluate effectiveness, safety and efficiency of case management approaches to the care of people who frequently call the emergency ambulance service, and gain an understanding of barriers and facilitators to implementation.

OBJECTIVES

(1) Develop an understanding of predicted mechanisms of change to underpin evaluation. (2) Describe epidemiology of sustained high users of 999 services. (3) Evaluate case management approaches to the care of people who call the 999 ambulance service frequently in terms of: (i) Further emergency contacts (999, emergency department, emergency admissions to hospital) (ii) Effects on other services (iii) Adverse events (deaths, injuries, serious medical emergencies and police arrests) (iv) Costs of intervention and care (v) Patient experience of care. (4) Identify challenges and opportunities associated with using case management models, including features associated with success, and develop theories about how case management works in this population.

METHODS AND ANALYSIS

We will conduct a multisite mixed-methods evaluation of case management for people who use ambulance services frequently by using anonymised linked routine data outcomes in a 'natural experiment' cohort design, in four regional ambulance services. We will conduct interviews and focus groups with service users, commissioners and emergency and non-acute care providers. The planned start and end dates of the study are 1 April 2019 and 1 September 2022, respectively ETHICS AND DISSEMINATION: The study received approval from the UK Health Research Authority (Confidentiality Advisory Group reference number: 19/CAG/0195; research ethics committee reference number: 19/WA/0216).We will collate feedback from our Lived Experience Advisory Panel, the Frequent Caller National Network and Research Management Group for targeted dissemination activities.

Nurse-led care versus usual care on cardiovascular risk factors for patients with type 2 diabetes: a systematic review and meta-analysis

OBJECTS

This study aims to systematically evaluate the effectiveness of nurse-led cares on cardiovascular risk factors among individuals with type 2 diabetes mellitus.

DESIGN

Systematic review and meta-analysis.

METHODS

The electronic databases PubMed, EMBASE, CINAHL and Cochrane Library databases were searched for randomised controlled trials of nurse-led care for individuals with type 2 diabetes mellitus (T2DM) published in English from inception to 23 December 2021. Random effects models were used to calculate weighted mean differences (WMD) with 95%CI.

RESULTS

13 articles were included in the meta-analysis, with a total of3757 participants. Considering baseline measurements, pooled analysis showed that nurse-led care significantly decreased the glycosylated haemoglobin (HbA1c) (WMD=-0.68 mmol/L; 95% CI -0.85 to -0.52; p<0.001), body mass index (BMI) (WMD=-0.54 kg/m²; 95% CI: -0.97 to -0.11; p=0.01) and systolic blood pressure (SBP) (WMD=-1.17 mmHg; 95% CI: -2.11 to -0.22; p=0.02) for patients with T2DM. But there was no difference in low-density lipoprotein cholesterol (LDL-c) (WMD=-2.50 mg/dL ; 95% CI: -5.07 to 0.08; p=0.06) between the nurse-led and control groups.

CONCLUSION

Nurse-led care is an effective and accessible intervention that could improve HbA1c, SBP, BMI levels among individuals with T2DM.

PROSPERO REGISTRATION NUMBER

CRD42021248275.

Patient and provider's perspective on barriers and facilitators for medication adherence among adult patients with cardiovascular diseases and diabetes mellitus in India: a qualitative evidence synthesis

OBJECTIVE

To explore the various stakeholders' perspectives on barriers and facilitators for medication adherence among patients with cardiovascular diseases (CVDs) and diabetes mellitus (DM)in India.

DESIGN

Systematic review of qualitative studies.

DATA SOURCES

A comprehensive systematic search was conducted in Medline, Cochrane Library, Science Direct and Google Scholar from January 2010 to July 2020. We included all qualitative peer-reviewed studies, reporting barriers and facilitators of medication adherence, from India, for our current review.

DATA EXTRACTION AND SYNTHESIS

Data extraction was performed by two independent authors who also assessed the quality of included studies using the Critical Appraisal Skills Programme criteria. This qualitative evidence synthesis adhered to the enhancing transparency in reporting the synthesis of qualitative research checklist RESULTS: In total, 18 studies were included. Major barriers reported were lack of understanding about the disease, complications related to non-adherence, followed by forgetfulness, lack of family support and risk communication. Health system-related barriers such as accessibility, affordability and acceptability were also reported by majority of the studies. Creation of peer support groups, digital reminder systems, integration of native Indian systems of India, physiotherapy and geriatric clinics at the primary healthcare level and innovations in patient care were suggested to counter these barriers in medication adherence.

CONCLUSION

Such patient-specific targeted interventions need to be developed to achieve better control among patients with CVD and DM.PROSPERO registration numberCRD42020199529.

A randomised controlled trial of a probiotic and a prebiotic examining metabolic and mental health outcomes in adults with pre-diabetes

AIMS

To evaluate the effect of the probiotic Lactobacillus rhamnosus HN001 and/or cereal enriched with oat-derived beta-glucan (OBG) on metabolic and mental health outcomes when administered to adults with pre-diabetes.

DESIGN

2×2 factorial design randomised, parallel-groups placebo-controlled; double-blinded for probiotic, single-blinded for cereals.

PARTICIPANTS

Community-dwelling adults aged 18-80 years with pre-diabetes: glycated haemoglobin (HbA_1c) 41-49 mmol/mol.

INTERVENTIONS

Capsules containing Lactobacillus rhamnosus (HN001) (6×10⁹ colony-forming units/day), or placebo capsules; and cereal containing 4 g/day OBG or calorie-matched control cereal, taken daily, for 6 months. Study groups were: (A) HN001 capsules+OBG cereal; (B) HN001 capsules+control cereal; (C) placebo capsules+OBG cereal and (D) placebo capsules+control cereal.

OUTCOME MEASURES

Primary outcome: HbA_1c at 6 months.

SECONDARY OUTCOMES

fasting plasma glucose, fasting insulin, homeostatic model assessment of insulin resistance, fasting lipids, blood pressure, body weight, waist circumference, body mass index and mental well-being.

RESULTS

153 participants were randomised. There was complete HbA_1c outcome data available for 129 participants. At 6 months the mean (SD) HbA_1c was 45.9 (4.4) mmol/mol, n=66 for HN001, and 46.7 (4.3) mmol/mol, n=63 for placebo capsules; 46.5 (4.0) mmol/mol, n=67 for OBG and 46.0 (4.6) mmol/mol n=62 for control cereal. The estimated difference between HN001-placebo capsules was -0.83, 95% CI -1.93 to 0.27 mmol/mol, p=0.63, and between OBG-control cereals -0.17, 95% CI -1.28 to 0.94 mmol/mol, p=0.76. There was no significant interaction between treatments p=0.79. There were no differences between groups or significant interactions between treatments for any of the secondary outcomes.

CONCLUSIONS

This study found no evidence of clinical benefit from the supplementation with either HN001 and/or cereal containing 4 g OBG on HbA_1c and all secondary outcomes relevant to adults with pre-diabetes.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clincial Trials Registry number ACTRN12617000990325.

Qualitative focus group interview study of communication between patients, dentists and physicians for efficient osteonecrosis of the jaw practices

OBJECTIVES

To investigate problems and the current status of existing methods of communication between patients, dentists and physicians for the prevention and treatment of medication-related osteonecrosis of the jaw (MRONJ).

DESIGN

A focus group interview study with a descriptive design using qualitative content analysis of transcripts.

SETTING

Secondary care in Korea.

PARTICIPANTS

3 patient groups and 4 health professional groups in a total of 32 participants including patients with osteoporosis or bone metastasis, dentists and physicians.

RESULTS

This study revealed that patients lacked medical knowledge of osteoporosis drugs, whereas dentists and physicians lacked each other's expertise. All patients reported undergoing dental treatments during the osteoporosis drug treatment, but dentists and physicians had different MRONJ experiences depending on their work setting in primary or secondary care. Patients expressed dissatisfaction with the current system of communication with health professionals via letter as they found this to be a slow process. Dentists and physicians reported the need for effective communication because they felt defensive when sending and receiving medical consults.

CONCLUSIONS

Despite the low incidence of MRONJ among patients with osteoporosis, it is difficult to treat; thus, it is necessary to inform dentists, physicians and patients about the importance of MRONJ prevention. To this end, close communication among all involved stakeholders about osteoporosis drugs is required.

Risk and incidence of cognitive impairment in patients with chronic kidney disease and diabetes: the results from a longitudinal study in a community cohort of patients and an age and gender-matched control cohort in North Wales, UK

OBJECTIVES

The aim of the current investigation is to estimate the incidence and risk for neurocognitive disorders (NCD) in a chronic kidney disease (CKD) cohort with diabetes, compared with an age and sex-matched control cohort.

DESIGN

Longitudinal follow-up.

SETTING

District general hospital North Wales, UK.

PARTICIPANTS

Ninety-two patients with CKD and an age and gender-matched sample of 143 controls at baseline and at approximately 36 months.

INTERVENTIONS

Cognitive function was assessed in the patients with CKD (mean age 75.8±9.1; 49 men: 43 women) and the control cohort (mean age 74.4±6.2; 71 men: 72) at baseline and at approximately 36 months. An NCD diagnosis was based on patient, informant, case note review, neuropsychological assessment and application of Diagnostic and Statistical Manual of Mental disorders V.5 (DSM-5) for an NCD and Petersen's criteria for mild cognitive impairment.

RESULTS

Follow-up neuropsychological assessment and application of DSM-5 criteria of the cognitively normal patients and controls revealed, 25/92 (27%) of the CDK and 20/143 (13.9%) in the control cohort developed an NCD. The CKD cohort had a twofold increased risk for the development of an NCD compared with the controls, adjusted for age and sex. The incidence rate for an NCD in the CKD cohort was 10.5 and 5.1 in the controls, respectively. No association was observed with the stage of CKD and cognitive function.

CONCLUSIONS

This longitudinal investigation found that patients with CKD have a twofold increased risk for the development of an NCD. The current investigation highlighted the need to recognise that NCD in patients with CKD is a common comorbidity and that they are at a much higher risk for the development of a significant neurodegenerative disorders. In view of these risks, neuropsychological screening and assessment should be incorporated into normal CKD clinical practice and management.

Comparison of the effects on cardiovascular events between use of metformin and dipeptidyl peptidase-4 inhibitors as the first-line hypoglycaemic agents in Japanese patients with type 2 diabetes mellitus: a claims database analysis

OBJECTIVES

To compare the risk of cardiovascular events from the initiation of therapy between metformin and dipeptidyl peptidase-4 inhibitors (DPP-4i) as first-line therapy.

DESIGN

Retrospective cohort study using two claims databases.

SETTING

The MDV database (provided by Medical Data Vision) comprised data from acute care hospitals, and the JMDC database (provided by JMDC) comprised data from individuals covered by health insurance societies.

PARTICIPANTS

Those who were diagnosed with type 2 diabetes at ≥18 years, prescribed metformin or DPP-4i as the first-line hypoglycaemic agent, had medical records of ≥6 months before the index prescription and had available glycated haemoglobin (HbA1c) data for the period, including the index date and 30 days before it (defined as the baseline) were included. Those diagnosed with type 1 diabetes and/or a history of myocardial infarction (MI) or cerebrovascular diseases were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcomes were cumulative risks from Kaplan-Meier curves or HRs of patients prescribed metformin compared with DPP-4i. The primary endpoint was the diagnosis of MI or stroke associated with hospitalisation. Patient demographics, prescribed drugs and laboratory test values of HbA1c and estimated glomerular filtration rate at baseline were adjusted. The study period starting from the index included treatment after initial monotherapy.

RESULTS

Overall, 2089 and 6686 patients in the MDV database and 1506 and 3635 in the JMDC database were prescribed metformin and DPP-4i, respectively. The HR of the primary endpoint was 0.879 with no statistical significance (95% CI 0.534 to 1.448, p=0.613) in the MDV database, while it was significantly lower, 0.398 (95% CI 0.213 to 0.742, 0.004) in the JMDC database.

CONCLUSIONS

Patients who received metformin as first-line therapy may have reduced cardiovascular events than those receiving DPP-4i. This study conforms to previous Japanese database studies, despite the consideration of its limitation being an observational design.

Preventing type 2 diabetes, overweight and obesity in the Norwegian primary healthcare: a longitudinal design with 60 months follow-up results and a cross-sectional design with comparison of dropouts versus completers

OBJECTIVES

Studies have demonstrated that it is possible to prevent type 2 diabetes for individuals at high risk, but long-term results in the primary healthcare are limited and high dropout rates have been reported.

DESIGN

A longitudinal design was used to study changes in participants' diabetes risk and anthropometrics from baseline to 60 months follow-up. A cross-sectional design was applied to investigate differences between dropouts and completers of the 60 months follow-up.

SETTING

Healthy Life Centres in the Norwegian primary healthcare.

PARTICIPANTS

189 individuals aged >18 years with a Finnish Diabetes Risk Score ≥12 and/or a body mass index (BMI) ≥25 kg/m² were included and offered to attend Healthy Life Centre programmes for 12 months. Measurements were performed annually up to 60 months after inclusion.

INTERVENTIONS

Healthy Life Centres arrange behavioural programmes including physical activity offers and dietary courses as part of the primary healthcare. This study offered individuals to attend Healthy Life Centre programmes and followed them for 60 months.

PRIMARY OUTCOME

Assess changes in participants' diabetes risk, cardiovascular measures and anthropometrics from baseline to 60 months.

SECONDARY OUTCOME

Investigate characteristics of dropouts compared with completers of 60 months follow-up.

RESULTS

For participants at 60 months follow-up, diabetes risk and anthropometrics decreased (p<0.001). Out of 65 participants classified as high risk for diabetes at baseline, 27 (42%) changed to being at moderate risk at 60 months follow-up. Remission of diabetes was seen for six of nine participants. Of 189 participants enrolled in the programme, 54 (31%) dropped out at any given point before 60 months follow-up. Dropouts were younger with higher, BMI, weight and waist circumference compared with the completers (p<0.001).

CONCLUSIONS

Having a long-term commitment for participants in primary healthcare interventions could be beneficial for the reduction of diabetes risk and improvement of anthropometrics as shown at the 60 months follow-up.

TRIAL REGISTRATION NUMBER

NCT01135901.