HbA1c: a review of analytical and clinical aspects

New Succinimide-Thiazolidinedione Hybrids as Multitarget Antidiabetic Agents: Design, Synthesis, Bioevaluation, and Molecular Modelling Studies

Diabetes mellitus (DM) is a metabolic disorder majorly arising from the pathophysiology of the pancreas manifested as a decline in the insulin production or the tissue's resistance to the insulin. In this research, we have rationally designed and synthesized new succinimide-thiazolidinedione hybrids for the management of DM. In a multistep reaction, we were able to synthesize five new derivatives (10a-e). All the compounds were new containing a different substitution pattern on the N-atom of the succinimide ring. Initially, all the compounds were tested against the in vitro α-glucosidase, α-amylase, PTP1B, and DPP4 targets. In all of these targets, the compound 10d was observed to be the most potential antidiabetic agent. Based on this, the antidiabetic activity of the compound 10d was further investigated in experimental animals, which overall gave us encouraging results. The molecular docking studies of the compound 10d was also performed against the target enzymes α-glucosidase, α-amylase, PTP1B, and DPP4 using MOE. Overall, we observed that we have explored a new class of compounds as potential antidiabetic agents.

Comparison of diagnostic accuracy for diabetes diagnosis: A systematic review and network meta-analysis

Aim

Fasting Plasma Glucose (FPG) and Hemoglobin A1c (HbA1c) are used as diagnostic tests for diagnosing diabetes mellitus, but it is unclear which test has the best diagnostic accuracy. This systematic review and network meta-analysis aimed to estimate the diagnostic accuracy of HbA1c ≥ 6.5%, FPG ≥ 126 mg/dl, and the combination of HbA1c ≥ 6.5% or FPG ≥ 126 mg/dl (HbA1c| FPG), compared with Oral Glucose Tolerance Test (OGTT) ≥ 200 mg/dl for diagnosis diabetes.

Materials and methods

We performed a comprehensive search in PubMed, Embase, Cochrane Library, and Scopus from inception to September 24th, 2021. Inclusion criteria were any study design comparing HbA1c ≥ 6.5%, FPG ≥ 126 mg/dl, and HbA1c ≥ 6.5% or FPG ≥ 126 mg/dl with OGTT ≥ 200 mg/dl as the reference test. Data were independently extracted, risk of bias was assessed using QUADAS-2 by two reviewers. Network meta-analysis was done using a bivariate regression model using the Bayesian framework. The relative ranking of all tests was also assessed.

Results

Out of 5,026 studies, 73 were included. The sensitivities of HbA1c, FPG, and HbA1c| FPG were 0.51 [95% Credible Interval (CrI): 0.43, 0.58], 0.49 (95% CrI: 0.43, 0.55), and 0.64 (95% CrI: 0.51, 0.75), while the specificities were 0.96 (95% CrI: 0.94, 0.97), 0.98 (95% CrI: 0.97, 0.98), and 0.95 (95% CrI: 0.88, 0.98), respectively. The corresponding positive likelihood ratios (LR) were 13.36 (95% CrI: 8.91, 20.72), 21.94 (95% CrI: 15.04, 31.88), and 11.78 (95% CrI: 5.48, 26.56). HbA1c| FPG is superior based on sensitivity, whereas FPG is ranked best based on specificity and positive LR.

Conclusion

Our findings suggest that FPG ≥ 126 mg/dl should be recommended as the best diagnostic test for diabetes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021282856.

A Systematic Review and Meta-Analysis of Continuous Subcutaneous Insulin Infusion vs. Multiple Daily Injections in Type-2 Diabetes

Diabetes mellitus (DM) has a growing prevalence worldwide, even in developing countries. Many antidiabetic agents are used to improve glycemic control; however, in cases of an insufficient outcome, insulin is administered. Yet, the timing of proper insulin administration is still a subject of intense research. To date, there have been no recommendations or guidelines for the use of continuous subcutaneous insulin infusion (CSII) in Type 2 Diabetes Mellitus (T2DM). In the present study, we have performed a meta-analysis to evaluate the use of CSII in patients with T2DM. An extensive literature search was conducted through the electronic databases Pubmed, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) from October 2019-May 2022, for interventional studies related to T2DMI and CSII versus multiple daily injections (MDI). We included articles published in the English language only, yielding a total of thirteen studies. We found better outcomes in patients receiving CSII, in regard to glycated hemoglobin (HbA1c) and total insulin dose. In contrast, fasting plasma glucose and body weight did not show statistically significant differences between the two groups. Our analyses showed that CSII could be beneficial in patients with T2DM in order to achieve their glucose targets.

FHL3 promotes the formation of fast glycolytic muscle fibers by interacting with YY1 and muscle glycolytic metabolism

The proportions of the various muscle fiber types are important in the regulation of skeletal muscle metabolism, as well as animal meat production. Four-and-a-half LIM domain protein 3 (FHL3) is highly expressed in fast glycolytic muscle fibers and differentially regulates the expression of myosin heavy chain (MyHC) isoforms at the cellular level. Whether FHL3 regulates the transformation of muscle fiber types in vivo and the regulatory mechanism is unclear. In this study, muscle-specific FHL3 transgenic mice were generated by random integration, and lentivirus-mediated gene knockdown or overexpression in muscles of mice or pigs was conducted. Functional analysis showed that overexpression of FHL3 in muscles significantly increased the proportion of fast-twitch myofibers and muscle mass but decreased muscle succinate dehydrogenase (SDH) activity and whole-body oxygen consumption. Lentivirus-mediated FHL3 knockdown in muscles significantly decreased muscle mass and the proportion of fast-twitch myofibers. Mechanistically, FHL3 directly interacted with the Yin yang 1 (YY1) DNA-binding domain, repressed the binding of YY1 to the fast glycolytic MyHC2b gene regulatory region, and thereby promoted MyHC2b expression. FHL3 also competed with EZH2 to bind the repression domain of YY1 and reduced H3K27me3 enrichment in the MyHC2b regulatory region. Moreover, FHL3 overexpression reduced glucose tolerance by affecting muscle glycolytic metabolism, and its mRNA expression in muscle was positively associated with hemoglobin A1c (HbA1c) in patients with type 2 diabetes. Therefore, FHL3 is a novel potential target gene for the treatment of muscle metabolism-related diseases and improvement of animal meat production.

The Impact of Carbamylation and Anemia on HbA1c's Association With Renal Outcomes in Patients With Diabetes and Chronic Kidney Disease

OBJECTIVE

Glycated hemoglobin (HbA1c) can predict risk for microvascular complications in patients with diabetes. However, HbA1c's reliability in chronic kidney disease (CKD) has been questioned, with concerns including competition from another posttranslational protein modification, carbamylation, acting on the same amino groups as glycation, and anemia with reduced erythrocyte lifespans leading to altered glycation accumulation. We investigated whether carbamylation and anemia modify the impact of HbA1c on renal outcomes in patients with diabetes and CKD.

RESEARCH DESIGN AND METHODS

In 1,516 participants from the Chronic Renal Insufficiency Cohort study with diabetes and CKD, Cox regression models were applied to evaluate the association between HbA1c and CKD progression (composite of end-stage kidney disease or 50% decline in estimated glomerular filtration rate [eGFR]), stratified by carbamylated albumin (C-Alb) quartiles and anemia.

RESULTS

The mean eGFR was 38.1 mL/min/1.73 m2, mean HbA1c was 7.5% (58 mmol/mol), and median C-Alb was 8.4 mmol/mol. HbA1c was lower in the higher C-Alb quartiles. During a median follow-up of 6.9 years, 763 participants experienced CKD progression. Overall, higher HbA1c was associated with an increased risk of CKD progression (adjusted hazard ratio 1.07 [95% CI 1.02-1.13]). However, using stratified analyses, HbA1c was no longer associated with CKD progression in the highest C-Alb quartile, but did show a monotonic increase in CKD progression risk across each lower C-Alb quartile (P-interaction = 0.022). Anemia also modified the association between HbA1c and CKD progression (P-interaction = 0.025).

CONCLUSIONS

In patients with coexisting diabetes and CKD, the association between HbA1c and CKD progression is modified by carbamylation and anemia.

The influence of growth hormone on pediatric body composition: A systematic review

BACKGROUND

Growth hormone (GH) affects metabolism and regulates growth in childhood. The most prominent feature of GH deficiency (GHD) in children is diminished height velocity that eventually leads to short stature. In adult-onset GHD, lean body mass (LBM) is reduced, and visceral fat mass (FM) increased. Beneficial effects of GH treatment on body composition in adults with GHD, including an increase in muscle mass and a decrease in FM, are well established. Relatively few studies have investigated the effects of GH treatment on the body composition of pediatric patients with idiopathic or hypothalamic-pituitary disease-associated GH deficiency. This systematic review aimed to summarize available evidence relating to the effects of GH treatment on body composition in children with GHD.

METHODS

The PubMed, Science Direct, Cochrane Trials, and Embase databases, were searched with keywords including "GH", "body composition", "children", and "growth hormone" for English-language articles, published between January 1999 and March 2021. Two reviewers independently evaluated the search results and identified studies for inclusion based on the following criteria: participants had a confirmed diagnosis of GHD (as defined in each study); participants were pediatric patients who were receiving GH or had stopped GH treatment, regardless of whether they were pre- or post-pubertal; the intervention was recombinant human GH (rhGH; somatropin); and outcomes included changes in body composition during or after stopping GH therapy. Data extracted from each study included study quality, study sample characteristics, study interventions, and body composition. Data on fat-free mass and LBM were combined into a single category of LBM.

RESULTS

Sixteen studies reporting changes in body composition (i.e., FM and LBM) associated with GH treatment in children with GHD were identified and included in the review. Collectively, these studies demonstrated that FM decreased, and LBM increased in response to GH replacement therapy.

CONCLUSION

Despite study limitations (i.e., potential effects of diet and physical activity were not considered), we concluded that a periodic body composition assessment is required to ensure that a satisfactory body composition is achieved during GH replacement therapy in children with GHD.

Obstructive Sleep Apnea, Circadian Clock Disruption, and Metabolic Consequences

Obstructive sleep apnea (OSA) is a chronic disorder characterized by recurrent episodes of apnea and hypopnea during sleep. It is associated with various cardiovascular and metabolic complications, including type 2 diabetes mellitus (T2DM) and obesity. Many pathways can be responsible for T2DM development in OSA patients, e.g., those related to HIF-1 and SIRT1 expression. Moreover, epigenetic mechanisms, such as miRNA181a or miRNA199, are postulated to play a pivotal role in this link. It has been proven that OSA increases the occurrence of circadian clock disruption, which is also a risk factor for metabolic disease development. Circadian clock disruption impairs the metabolism of glucose, lipids, and the secretion of bile acids. Therefore, OSA-induced circadian clock disruption may be a potential, complex, underlying pathway involved in developing and exacerbating metabolic diseases among OSA patients. The current paper summarizes the available information pertaining to the relationship between OSA and circadian clock disruption in the context of potential mechanisms leading to metabolic disorders.

Relation Between HbA1c and Lipid Profile Among Prediabetics, Diabetics, and Non-diabetics: A Hospital-Based Cross-Sectional Analysis

INTRODUCTION

An unusually high blood glucose level is a hallmark of diabetes mellitus, with an imbalance between insulin levels and insulin sensitivity leading to an insulin functional deficit. Since it serves as both a risk indicator and a gauge of long-term glycemic control, the HbA1c concentration is a crucial component of standard diabetes treatment. The use of the HbA1c concentration in the diagnosis of diabetes is expanding as the test's accuracy increases. Dyslipidemic profiles can appear before type 2 diabetes manifests itself and are independent risk factors for the disease. Additionally, dyslipidemia, especially in diabetics, might affect pancreatic beta-cell survival and activity. This study was undertaken with the aim to find out any correlation between HbA1c and lipid profile among diabetics, prediabetics, and non-diabetics.

METHODS

A total of 1,000 individuals with age 18-60 years were included in the study (non-diabetics = 186, prediabetics = 238, diabetics = 576). HbA1c was estimated by capillary electrophoresis and a lipid profile was done using a fully automatic chemistry analyzer.

RESULT

Diabetes was found to be significantly associated with dyslipidemia. In diabetics, a statistically significant increase in the level of triglyceride and very low-density lipoprotein (VLDL) was seen as compared to prediabetics. Diabetic women were found to be significantly more dyslipidemic as compared to diabetic males. The mean HbA1c among diabetics was found to be 8.3.

CONCLUSION

In hyperglycemia-induced dyslipidemia, raised triglyceride and VLDL were the most common findings, and combined lipid abnormalities were more commonly seen as compared to a single abnormality in the lipid profile. Patients with poor glycemic control more commonly develop dyslipidemia, which may be a reason for an increased incidence of cardiovascular catastrophes in such patients.

The Value of Hemoglobin Glycation Index-Diabetes Mellitus System in Evaluating and Predicting Incident Stroke in the Chinese Population

We aimed to clarify the effect of the hemoglobin glycation index (HGI)–diabetes mellitus (DM) system in evaluating the risk of incident stroke. We followed up on 2934 subjects in rural regions of Northeast China, established Cox proportional hazards models to evaluate the effects of the HGI–DM system in describing stroke risk, and further conducted a discrimination analysis to confirm the improvement in HGI based on the traditional stroke risk model. After a median of 4.23 years of follow-up, 79 subjects developed stroke or related death. DM-high HGI condition significantly elevated the risk of incident stroke (hazard ratio (HR): 2.655, 95% confidence interval (CI): 1.251–5.636). In addition, higher HGI levels elevated the risk of stroke, even if the patients did not have DM (HR: 1.701, 95% CI: 1.136–2.792), but DM failed to bring an extra risk of incident stroke to patients with lower HGI levels (HR: 1.138, 95% CI: 0.337–3.847). The discrimination analysis indicated that the integrated discrimination index (IDI) of the HGI model was 0.012 (95% CI: 0.007–0.015) and that the net reclassification index (NRI) was 0.036 (95% CI: 0.0198–0.0522). These results indicated HGI was associated with the onset of stroke, and high HGI indicated an aggravated trend in glycemic status and increased risk of incident stroke. The HGI–DM system enabled us to identify the different glucose statuses of patients, to conduct suitable treatment strategies, as well as to improve the predictability of incident stroke based on the traditional model.

Advances in Nanomaterial-Based Biosensors for Determination of Glycated Hemoglobin

Diabetes is a major public health burden whose prevalence has been steadily increasing over the past decades. Glycated hemoglobin (HbA1c) is currently the gold standard for diagnostics and monitoring glycemic control in diabetes patients. HbA1c biosensors are often considered to be cost-effective alternatives for smaller testing laboratories or clinics unable to access other reference methods. Many of these sensors deploy nanomaterials as recognition elements, detection labels, and/or transducers for achieving sensitive and selective detection of HbA1c. Nanomaterials have emerged as important sensor components due to their excellent optical and electrical properties, tunable morphologies, and easy integration into multiple sensing platforms. In this review, we discuss the advantages of using nanomaterials to construct HbA1c sensors and various sensing strategies for HbA1c measurements. Key gaps between the current technologies with what is needed moving forward are also summarized.

Longitudinal study of the flash glucose monitoring system in type 1 diabetics: An mHealth ally in times of COVID-19

AIMS AND OBJECTIVES

The aim of this study was to assess the effect of the FreeStyle Libre device implantation in adult type 1 diabetics in a Health Area of Castilla La Mancha (Spain) during the COVID-19 pandemic.

BACKGROUND

FreeStyle Libre is a so-called mHealth device that supports health care. During COVID-1 confinement, diabetic patients could have improved their glycaemic monitoring thanks to these devices, although health care in these patients may have been limited due to confinement.

METHODS

A 12-month longitudinal study in which a total of 206 type I diabetics participated, belonging to a single health area. Sociodemographic and analytical data and the Self Care Inventory Revised questionnaire (SCI-R) were collected. STROBE checklist was followed.

RESULTS

The analysis showed differences related to the use of the sensor. After the study period, patients obtained better levels of basal glucose, glycosylated haemoglobin, creatinine, cholesterol, triglycerides and LDL. In addition, a significant increase in the total score of the SCI-R questionnaire was observed after the use of the monitor (MD -7.77; 95% CI -10.43, -8.29). The same occurred with different SCI-R items such as diet (MD -2.995; 95% CI -3.24, -2.57), glucose determination (MD -3.21; 95% CI -3.52, -2.91), medication administration (MD -2.58; 95% CI -2.53, -1.96) and hypoglycaemic episodes (MD -1.07; 95% CI -1.21, -0.93). In the analysis by groups, worse values of glycosylated haemoglobin and adherence to treatment (p < .05) were observed in overweight/obese subjects versus those with normal weight after one year of study.

CONCLUSION

The use of flash monitoring is related to better adherence to most of the recommended habits in diabetes. Nevertheless, there seems to be no relationship with an improvement in physical exercise and preventive aspects of diabetes. A good nursing intervention to support physical exercise and the use of mHealth devices could improve the control of diabetic patients.

RELEVANCE TO CLINICAL PRACTICE

The use of this mHealth device has shown positive results and reduced complications. Despite less contact with healthcare facilities due to the pandemic, type 1 diabetic patients have improved their blood results and adherence after using the device for one year. Nursing staff should focus on promoting physical activity and routine disease care in type 1 diabetics.

Continuous glucose monitoring metrics for earlier identification of pre-diabetes: protocol for a systematic review and meta-analysis

INTRODUCTION

Glycaemic variability and other metrics are not well characterised in subjects without diabetes. More comprehensive sampling as obtained with continuous glucose monitoring (CGM) may improve diagnostic accuracy of the transition from health to pre-diabetes. Our goal is to investigate the glycaemic system as it shifts from health to pre-disease in adult patients without diabetes using CGM metrics. New insights may offer therapeutic promise for reversing dysglycaemia more successfully with dietary, nutritional and lifestyle change before progression occurs to pre-diabetes and diabetes.

METHODS AND ANALYSIS

This systematic review will include comprehensive searches of the PubMed, Scopus, Cochrane Library and ClinicalTrials.gov databases, with restrictions set to studies published in the last 10 years in English and planned search date 10 March 2022. Reference lists of studies that meet eligibility criteria in the screening process will subsequently be screened for the potential inclusion of additional studies. We will include studies that examine CGM use and report diagnostic criteria such as fasting glucose and/or haemoglobin A1c such that we can assess correlation between CGM metrics and established diagnostic criteria and describe how CGM metrics are altered in the transition from health to pre-diabetes. The screening and data extraction will be conducted by two independent reviewers using Covidence. All included papers will also be evaluated for quality and publication bias using Cochrane Collaboration risk of bias tools. If there are two or more studies with quantitative estimates that can be combined, we will conduct a meta-analysis after assessing heterogeneity.

ETHICS AND DISSEMINATION

The systematic review methodology does not require formal ethical review due to the nature of the study design. Study findings will be publicly available and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022308222.

Blood hemoglobin A1c might predict adverse differences in heart rate variability in a diabetic population: Evidence from the Midlife in the United States (MIDUS) study

Background

Cardiac autonomic neuropathy in population with diabetes mellitus (DM) is frequent and linked with high risk of cardiovascular mortality. However, studies on whether blood hemoglobin A1c (HbA1c) levels are related to adverse differences in heart rate variability (HRV) in individuals with DM are scarce.

Aim

We aimed to investigate the association of blood HbA1c levels with adverse differences in HRV, which is an indicator of cardiac autonomic control, in adult individuals with and without DM.

Methods

Data were collected from the Midlife in the United States (MIDUS) study, and 928 individuals were analyzed for the relationship between blood HbA1c levels and HRV through a cross-sectional analysis.

Results

Participants with DM had significantly higher HRV than those without DM. The smooth curve suggested inverse relationships between blood HbA1c levels and HF- and LF-HRV seen in participants with DM but not in those without DM after controlling for all covariates (age, sex, BMI, smoking, number of drinking years and exercise). Furthermore, linear regression analysis demonstrated that elevated blood HbA1c levels did contribute to adverse differences in HF-HRV (Sβ= -0.118; 95% CI -0.208, -0.027; P=0.012) and LF-HRV (Sβ= -0.097; 95% CI -0.177, -0.017; P=0.019) after controlling for these covariates in participants with DM, while in participants without DM, blood HbA1c was not significantly related to adverse differences in HF-HRV (Sβ=0.095; 95% CI -0.059, 0.248; P=0.228) or LF-HRV (Sβ=0.043; 95% CI -0.103, 0.189; P=0.565). DM has a significant modifying effect on associations between blood HbA1c and adverse differences in HF-HRV (P for interaction=0.019) and LF-HRV (P for interaction=0.029).

Conclusions

We reported strong evidence that elevated blood levels of HbA1c were associated with adverse differences in HRV in the diabetic population but not in the nondiabetic population. This finding supported that long-term hyperglycemia is related to autonomic nerve injury in the diabetic population. Blood HbA1c might be a good indicator of cardiac autonomic neuropathy.

Ketogenic Diet Benefits to Weight Loss, Glycemic Control, and Lipid Profiles in Overweight Patients with Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trails

A ketogenic diet, characterized by low calories with high levels of fat, adequate levels of protein, and low levels of carbohydrates, has beneficial effects on body weight control in overweight patients. In the present study, a meta-analysis was conducted to investigate the role of a ketogenic diet in body weight control and glycemic management in overweight patients with type 2 diabetes mellitus (T2DM). In summary, we systematically reviewed articles from the Embase, PubMed, Web of Science and Cochrane Library databases and obtained eight randomized controlled trials for meta-analysis. The results show that a ketogenic diet had significantly beneficial effects on the loss of body weight (SMD, -5.63, p = 0.008), the reduction of waist circumference (SMD, -2.32, p = 0.04), lowering glycated hemoglobin (SMD, -0.38, p = 0.0008) and triglycerides (SMD, -0.36, p = 0.0001), and increasing high-density lipoproteins (SMD, 0.28, p = 0.003). Overall, these results suggest that a ketogenic diet may be an effective dietary intervention for body weight and glycemic control, as well as improved lipid profiles in overweight patients with T2DM. Hence, a ketogenic diet can be recommended for the therapeutic intervention of overweight patients with T2DM.

External quality assessment scheme for HbA1c assays in Thailand: A 5-year experience

Background

Thailand National External Quality Assessment Scheme (NEQAS) for HbA1c was established to evaluate the quality of HbA1c assays in Thailand in 2016.

Methods

HbA1c results from participating laboratories were compared to the target value assigned by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) reference system.

Results

The pass rates of participating laboratories during 2016-2020 were72-88%. The mean bias ranged between -0.19 and 0.20% of HbA1c. SD ranged from 0.30 to 1.08% of HbA1c. The overall coefficients of variation ranged from 4.46-15.66%.

Conclusions

Performance evaluation using IFCC assigned values indicated that different assay methods had an effect on HbA1c results. Participation in external quality assessment programs for HbA1c analysis is essential for improving laboratory quality and benefiting patient management.

Effect of anemia and erythrocyte indices on hemoglobin A1c levels among pregnant women

BACKGROUND

Anemia is a common disorder among pregnant women; however, the effect of anemia on hemoglobin A1c (HbA1c) levels has not been adequately explored. We aim to examine the influence of anemia on the HbA1c concentration and investigate the relationship between erythrocyte indices and HbA1c levels during pregnancy.

METHODS

We performed a retrospective analysis of 1369 pregnant Chinese women. The clinical and analytical data were collected. Independent t-test and Analysis of Variance were used for comparative studies, and multiple linear regression analysis was used to identify the association between erythrocyte indices and HbA1c.

RESULTS

The differences in HbA1c between non-anemia and mild anemia were negligible, and the differences in HbA1c between non-anemia and moderate anemia were well within the allowable variability for clinical practice (≥0.5% absolute changes). Mean corpuscular hemoglobin (MCH) correlated with HbA1c significantly, independent of pregnancy, trimester, and anemia. The distinction of HbA1c levels between grades of Hb became no significant (P = 0.955), while differences between trimesters persisted after adjusting for MCH.

CONCLUSION

Mild and moderate anemia should not be the primary concern when using HbA1c to monitor blood glucose in pregnancy. MCH showed negative correlations with HbA1c independently, suggesting a previously unknown mechanism affecting HbA1c levels.

Nonalcoholic Fatty Liver Disease and Altered Neuropsychological Functions in Patients with Subcortical Vascular Dementia

NAFLD is the most common cause of abnormality in liver function tests. NAFLD is considered a potential cardiovascular risk factor and is linked to cardiovascular risk factors such as obesity, hypertension, type 2 diabetes, and dyslipidemia. Few previous studies have investigated whether NAFLD could be independently associated with cognitive impairment. The current study aims to find a possible role of NAFLD in the development of subcortical vascular dementia (sVaD). We considered NAFLD as a possible independent vascular risk factor or, considering its metabolic role, associated with other commonly accepted sVaD risk factors, i.e., lack of folate, vitamin B12, and vitamin D-OH25, and increased levels of homocysteine. We studied 319 patients diagnosed with sVaD. All patients underwent an abdominal ultrasound examination to classify steatosis into four levels (1-none up to 4-severe). sVaD patients were divided into two groups according to the presence or absence of NAFLD. Our results demonstrated a strong correlation between NAFLD and sVaD. Patients with the two comorbidities had worse neuropsychological outcomes and a worse metabolic profile. We also found a robust relationship between NAFLD and severe vitamin B12, folate, vitamin D hypovitaminosis, and higher hyperhomocysteinemia levels. This way, it is evident that NAFLD contributes to a more severe metabolic pathway. However, the strong relationship with the three parameters (B12, folate and vitamin D, and homocysteinemia) suggests that NAFLD can contribute to a proinflammatory condition.

Association of change in haemoglobin A1c with adverse perinatal outcomes in women with pregestational diabetes

AIMS

To determine whether a net decline in glycosylated haemoglobin (HbA_1c ) from early to late pregnancy is associated with lower risk of adverse perinatal outcomes at delivery among women with pregestational diabetes.

METHODS

A retrospective analysis from 2012 to 2016 at a tertiary care centre. The exposure was the net change in HbA_1c from early (<20 weeks gestation) to late pregnancy (≥20 weeks gestation). Primary outcomes were large for gestational age (LGA) and neonatal hypoglycaemia. The association between outcomes per 6 mmol/mol (0.5%) absolute decrease in HbA_1c was evaluated using modified Poisson regression, and adjusted for age, body mass index, White Class, early HbA_1c and haemoglobin and gestational age at HbA_1c measurement and delivery.

RESULTS

Among 347 women with pregestational diabetes, HbA_1c was assessed in early (9 weeks [IQR 7,13]) and late pregnancy (31 weeks [IQR 29,34]). Mean HbA_1c decreased from early (59 mmol/mol [7.5%]) to late (47 mmol/mol [6.5%]) pregnancy. Each 6 mmol/mol (0.5%) absolute decrease in HbA_1c was associated with a 12% reduced risk of LGA infant (30%, aRR:0.88; 95% CI:0.81,0.95), and a 7% reduced risk of neonatal hypoglycaemia (35%, aRR:0.93; 95% CI:0.87,0.99). Preterm birth (36%, aRR:0.93; 95% CI:0.89,0.98) and neonatal intensive care unit admission (55%, aRR:0.95; 95% CI:0.91,0.98) decreased with a net decline in HbA_1c , but not caesarean delivery, pre-eclampsia, shoulder dystocia and respiratory distress syndrome.

CONCLUSIONS

Women with pregestational diabetes with a reduction in HbA_1c may have fewer infants born LGA or with neonatal hypoglycaemia. Repeated assessment of HbA_1c may provide an additional measure of glycaemic control.

Performance Evaluation of the i-SmartCare 10 Analyzer and Method Comparison of Six Point-of-Care Blood Gas Analyzers

Blood gas, electrolyte, glucose, and lactate level measurement have an immediate and critical impact on patient care. We evaluated the performance of i-SmartCare 10 (i-SENS Inc., Seoul, Korea) and conducted a method comparison study of five point-of-care (POC) analyzers with i-SmartCare 10 as the comparator, according to the CLSI guidelines. Ten analytes (pH, pCO₂, pO₂, Na⁺, K⁺, Cl^-, iCa²⁺, glucose, lactate, and Hct) were tested on six analyzers: i-SmartCare 10, ABL90 FLEX PLUS (Radiometer Medical ApS, Copenhagen, Denmark), i-Stat (Abbott Point of Care Inc., Princeton, NJ, USA), RapidLab 1265 (Siemens Healthcare Diagnostics Inc., Tarrytown, NY, USA), Stat Profile pHOx Ultra (Nova Biomedical, Waltham, MA, USA), and Gem Premier 5000 (Instrumentation Laboratory, Bedford, MA, USA). The total imprecision and linearity (r²>0.99) were excellent, except for a few analytes that narrowly escaped the preset criteria. Interference was noted for Na⁺ in the presence of a high K⁺ level and for iCa²⁺ in the presence of high K⁺ and Mg²⁺ levels. Forty of 48 items demonstrated either a proportional or systematic difference in regression analysis; the relative mean difference (%) of 14/48 items escaped the allowable total error in the difference plot analysis. i-SmartCare 10 shows acceptable performance, and using a single POC blood gas analyzer is recommended for monitoring.

Fasting blood glucose-to-glycated hemoglobin ratio and all-cause mortality among Chinese in-hospital patients with acute stroke: a 12-month follow-up study

BACKGROUND

Stroke is a leading cause of death and functional impairment in older people. To assess the prospective association between fasting blood glucose-to-glycated hemoglobin ratio and all-cause mortality and poor prognosis in stroke patients.

METHODS

A total of 971 Chinese inpatients with acute stroke (mean age of 65.7) were consecutively enrolled in the prospective clinical study and followed up for 12 months after discharge. Stress hyperglycemia was measured using the ratio of fasting blood glucose (FBG, mmol/L)/glycated hemoglobin (HbA1c, %). The primary outcome was all-cause mortality, and secondary outcomes were poor prognosis defined as infectious complications, a National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, a Barthel Index score ≤ 60, or a modified Rankin Scale (mRS) score of 3-6, presented as multivariate-adjusted odds ratios (ORs) with 95% confidence intervals (CIs) across the quartiles of the FBG/HbA1c ratio.

RESULTS

There were 35 (4.1%) all-cause deaths at 3 months and 85 (11.4%) at 12 months. The inpatients with the highest quartile of the FBG/HbA1c ratio had a higher risk of all-cause death at 3 months (adjusted OR: 5.16, 95% CI: 1.03-25.74) and at 12 months (adjusted OR: 2.59, 95% CI: 1.14-5.89)) and a higher risk of infectious complications (adjusted OR 2.37, 95% CI 1.27-4.43) and dysfunction (adjusted OR 1.79, 95% CI 1.06-3.01) during hospitalization than inpatients with the lowest quartile.

CONCLUSIONS

Stress hyperglycemia, measured by the FBG/HbA1c ratio, was associated with an increased risk of adverse outcomes, including all-cause death, infectious complications, and dysfunction after stroke.

Comparing different operationalizations of allostatic load measured in mid-life and their patterning by race and cumulative life course socioeconomic status

Since its conceptualization, there has been a lack of consensus on the best way to operationalize allostatic load (AL). As a marker of the cumulative, physiological wear and tear on the body resulting from chronic exposure to stressors, it follows that AL should be higher among people who have faced more stressful life experiences. Thus, the purpose of this study was to construct AL scores using different operationalizations and, as a measure of construct validity, compare whether each construction produced expected disparities in AL by race and a composite socioeconomic status (SES) variable which accounts for measures over the life course; we also explored differences by sex. We conducted the study in a sample of 45-52-year-old offspring from the Child Health and Development Studies, a longitudinal birth cohort established in the early 1960s. AL scores were constructed in 6 different ways and included 10 biomarkers from inflammatory, neuroendocrine, cardiovascular, and metabolic systems. Our main approach to constructing AL was to sum across high-risk biomarker quartiles, correct for medication use, and use sex-specific high-risk quartiles for specific biomarkers. Alternative constructions did not use sex-specific quartiles and/or weighted biomarkers within subsystems and/or did not correct for medication use. We estimated differences in AL scores by race, SES, sex and their pairwise interactions. All constructions of AL, including the main approach, produced expected disparities by race (higher scores for Black vs. non-Black participants) and life course SES (higher scores for low vs. high SES participants). However, disparities by sex only emerged when the AL score was constructed via approaches that did not use sex-specific high-risk quartiles; for these alternative constructions, overall, female participants had higher AL scores than male participants and Black female participants had the highest AL scores in the sample. For most constructions, the pairwise interaction between sex and SES, showed a stronger disparity in AL scores between low and high-SES female compared with low- and high-SES male participants; this suggests that, in terms of lowering AL, high life course SES may be more important for female than male participants. In conclusion, our results suggest that the basic AL concept is consistently expressed in different operationalizations, making it an especially useful and robust tool for understanding disparities by race and SES.

Undiagnosed Impaired Glucose Tolerance and Type-2 Diabetes in Acute Myocardial Infarction Patients: Fequency, Characteristics and Long-Term Mortality

Background

In this study we investigated the prevalence of undiagnosed impaired glucose tolerance and type-2-diabetes (T2D) among patients with acute myocardial infarction (AMI) and prospectively analyzed whether these patients have a higher long-term mortality.

Methods

The analysis was based on 2,317 AMI patients aged 25–84 years from the population-based Myocardial Infarction Registry Augsburg, recruited between 2009 and 2014 and followed-up until 2019 (median follow-up time 6.5 years [IQR: 4.9–8.1]). AMI patients with a diagnosis of diabetes were divided into a high (>7.0%) and a low HbA1c group (≤7.0%) according to HbA1c values at admission. The remaining patients (without known diabetes) were grouped into normal (<5.7%), elevated (5.7–6.4%), and high (≥6.5%) HbA1c groups. In a multivariable-adjusted COX regression analysis, the association between HbA1c groups and long-term mortality was investigated. Linear regression models were used to identify AMI patients with elevated HbA1c values by means of personal characteristics.

Results

At admission, 29.5% of all patients reported a diagnosis of diabetes. Of all patients without known diabetes, 5.4% had HbA1c values of ≥ 6.5 and 37.9% had HbA1c values between 5.7 and 6.4%. The fully adjusted Cox regression model showed a non-significant trend toward higher long-term mortality for AMI patients with increased HbA1c values (HbA1c 5.7–6.4% HR: 1.05 [0.79–1.38], HbA1c > 6.5% HR: 1.34 [0.77–2.31]). A linear regression model including the variables admission serum glucose, BMI, age, sex and type of infarction (STEMI, NSTEMI) showed only poor prediction of HbA1c values (R²: 11.08%).

Conclusion

A fairly high number of AMI patients without known diabetes have elevated HbA1c values. Though we could not prove a higher risk of premature mortality in these patients, early detection and adequate therapy might lead to reduced diabetes-associated complications and improve long-term outcomes.

Epigenetic Modifications and Non-Coding RNA in Diabetes-Mellitus-Induced Coronary Artery Disease: Pathophysiological Link and New Therapeutic Frontiers

Diabetes mellitus (DM) is a glucose metabolism disorder characterized by chronic hyperglycemia resulting from a deficit of insulin production and/or action. DM affects more than 1 in 10 adults, and it is associated with an increased risk of cardiovascular morbidity and mortality. Cardiovascular disease (CVD) accounts for two thirds of the overall deaths in diabetic patients, with coronary artery disease (CAD) and ischemic cardiomyopathy as the main contributors. Hyperglycemic damage on vascular endothelial cells leading to endothelial dysfunction represents the main initiating factor in the pathogenesis of diabetic vascular complications; however, the underlying pathophysiological mechanisms are still not entirely understood. This review addresses the current knowledge on the pathophysiological links between DM and CAD with a focus on the role of epigenetic modifications, including DNA methylation, histone modifications and noncoding RNA control. Increased knowledge of epigenetic mechanisms has contributed to the development of new pharmacological treatments ("epidrugs") with epigenetic targets, although these approaches present several challenges. Specific epigenetic biomarkers may also be used to predict or detect the development and progression of diabetes complications. Further studies on diabetes and CAD epigenetics are needed in order to identify possible new therapeutic targets and advance personalized medicine with the prediction of individual drug responses and minimization of adverse effects.

Novel use of menstrual blood for monitoring glycaemic control in patients with diabetes: a proof-of-concept study

BACKGROUND

Glycated haemoglobin (HbA1c) is the diagnostic and prognostic standard for clinical management of diabetes mellitus (DM). Unfortunately, patient adherence to guidelines for routine testing can be poor and there are significant gender-based disparities in DM management and outcomes. Recent evidence suggests that menstrual blood may be comparable to systemic blood for monitoring of common biomarkers. The objective of the present study was to assess the concordance of HbA1c levels between menstrual and systemic blood in healthy women and women with diabetes of reproductive age.

METHODS

In this prospective, observational cohort study, we enrolled healthy and diabetic (type 1 and type 2 DM) reproductive-age women (aged ≥18 and ≤45 years). Menstrual blood and venous systemic blood specimens were simultaneously obtained at time of menstruation, and analysed for HbA1c levels. Participants self-collected menstrual blood using a QPad, a novel, modified menstrual pad with an embedded dried blood spot strip.

RESULTS

Among 172 participants, 57.6% were healthy and 42.4% had a diagnosis of either type 1 or type 2 DM. There were no significant differences in mean HbA1c values in menstrual and systemic blood across the overall cohort or within the diabetic subgroup. Furthermore, HbA1c levels between blood sources were robustly correlated and demonstrated a significant linear relationship.

CONCLUSIONS

There is a strong concordance in HbA1c levels between menstrual and systemic blood. Empowered by self-collection technologies, these findings suggest that menstrual blood may serve as a reliable, non-invasive and potentially cost-effective alternative to serum for HbA1c monitoring among reproductive-age women with DM.

Comparison of three different HbA1c measurement methods - the Atellica®CH930, Capillary 3 Tera, and BioRad Variant Turbo II

AIM

HbA1c measurement is very useful for the follow-up and detection of glycemic disorder, since it is easier and faster test and is independent of the patient's fasting status. In this study, we aimed to perform the comparative evaluation of 3 different methods for HbA1c measurement including capillary electrophoresis, immunoturbidimetric assay and high-performance liquid chromatography-HPLC.

MATERIALS AND METHODS

This study comprised 134 leftover whole blood samples obtained from the subjects submitted for routine HbA1c testing. All blood samples were collected in EDTA-containing vacutainer tubes. The HbA1c levels were measured simultaneously using three different methods. Bias estimation, method agreement and concordance between the pairwise methods comparisons were evaluated by Bland-Altman plot and Passing-Bablok regression test.

RESULTS

HbA1c levels ranged from 3.8% to 13.4% and measured by three different methods to make the comparison. The median values of samples based on immunoturbidimetric method (6.05%, IQR = 1.80) were higher than capillary electrophoresis method (5.90%, IQR = 1.80) and HPLC (5.85%, IQR = 1.80) method. The study group was classified into three subgroups based on the HbA1c levels measured with the HPLC method: Group 1 (n = 57) was composed of subjects with HbA1c levels less than 5.7%, Group 2 (n = 35) had HbA1c levels between 5.7% and 6.4%, Group 3 (n = 42) had HbA1c levels equal and more than 6.5%.

CONCLUSION

To our knowledge, there is no study evaluating the HbA1c measurement on the Atellica^® CH 930 Analyzer. We compared the Atellica^®CH930 Analyzer with both HPLC and capillary electrophoresis. The Atellica^®CH930 Analyzer showed acceptable performance and a strong correlation with both mentioned methods.

Could nutrient supplements provide additional glycemic control in diabetes management? A systematic review and meta-analysis of randomized controlled trials of as an add-on nutritional supplementation therapy

This systematic review and meta-analysis assessed the antidiabetic effect of pharmaconutrients as an add-on in type 2 diabetes mellitus patients by pooling data from currently available randomized controlled trials (RCTs). Data sources included the PubMed and EMBASE, Cochrane Central Register of Controlled Trials. RCTs reporting changes in glycosylated hemoglobin (HbA1c), fasting blood glucose (FBG), or homeostasis model assessment of insulin resistance (HOMA-IR) levels following add-on pharmaconutritional therapies for T2DM patients consuming antidiabetic drugs were targeted. Using random-effects meta-analyses, we identified pharmaconutrients with effects on glycemic outcomes. Heterogeneity among studies was presented using I² values. Among 9537 articles, 119 RCTs with nine pharmaconutrients (chromium; coenzyme Q10; omega-3 fatty acids; vitamins C, D, and E; alpha-lipoic acid; selenium; and zinc) were included. Chromium (HbA1c, FBG, and HOMA-IR), coenzyme Q10 (HbA1c and FBG), vitamin C (HbA1c and FBG), and vitamin E (HbA1c and HOMA-IR) significantly improved glycemic control. Baseline HbA1c level and study duration influenced the effects of chromium and vitamin E on HbA1c level. Sensitivity analyses did not modify the pooled effects of pharmaconutrients on glycemic control. Administration of chromium, coenzyme Q10, and vitamins C and E for T2DM significantly improved glycemic control. This study has been registered in PROSPERO (CRD42018115229).

The association between depression symptom endorsement and glycemic outcomes in adolescents with type 1 diabetes

OBJECTIVE

The prevalence of depression among adolescents with type 1 diabetes is estimated to be 2-3 times higher than in the general population. In adults with type 1 diabetes and depression, short-term outcomes are worse compared to individuals just diagnosed with type 1 diabetes. This study aims to determine if depressive symptom endorsement is associated with glycemic outcomes and short-term complications in adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Analysis was conducted using electronic medical records from the T1D Exchange Quality Improvement Collaborative. Adolescents with type 1 diabetes, aged 12-18, receiving treatment in a diabetes clinic who had been screened for depression with the PHQ-9 between 2016 and 2018 were eligible for inclusion. Individuals must have also had HbA1c data available from the day of depression screening and from 10 to 24 weeks after screening; the final sample size was 1714.

RESULTS

Almost 30% of adolescents endorsed mild or greater (PHQ-9 ≥ 5) depressive symptoms. Endorsement of mild or greater depressive symptoms was associated with an 18% increased risk of an HbA1c ≥7.5% and a 42% increased risk of an HbA1c ≥9.0% on the day of screener administration. Depressive symptom endorsement was also associated with an 82% increased risk for DKA.

CONCLUSIONS

This study suggests that depression symptoms are associated with an increased risk for elevated HbA1c and short-term complications. With the rising incidence of type 1 diabetes in youth, routine screening, and appropriate management of depression is needed.

Associations between HbA1c-derived estimated average glucose and fasting plasma glucose in patients with normal and abnormal hemoglobin patterns

Fasting plasma glucose (FPG) and HbA1c are well-known tests for monitoring short and long-term glycemic control, respectively. Estimated average glucose (eAG) is derived from the HbA1c for expression in the same units as FPG. The present study aimed to evaluate the association between eAG and FPG values. This retrospective study was performed on 1285 patients who measured the FPG and HbA1c (capillary electrophoresis method) values on the same day. They were initially divided into 3 hemoglobin-pattern groups, normal, HbE, and high HbA₂, and then these 3 groups were further subdivided into whole group, subgroup 1 (HbA1c ≤ 7%) and subgroup 2 (HbA1c >7%) for analytical comparisons. The eAG values were calculated using Nathan's equation. The differences, agreements, and correlations between eAG and FPG were evaluated. Good agreements and strong positive correlations between eAG and FPG values were observed in all 3 whole groups. In subgroup analysis, the degrees of agreement and correlation depended on the level of glycemic control, as all associations became stronger with better glycemic control. Additionally, the HbA1c levels and different eAG-FPG values between the normal and other groups were not significantly different in either whole group or subgroup comparisons. Our study found good agreements and strong positive correlations between eAG and FPG in all groups, indicating that high HbA₂ or HbE did not affect the HbA1c levels or thus the associations between eAG and FPG. Reporting the eAG together with the HbA1c value should help improve the understanding of glycemic status in patients, leading to improved blood glucose control.

Associations between the TNMD rs4828038 and ACE2 rs879922 polymorphisms and preeclampsia susceptibility: a case-control study

A case-control study was designed to investigate the association between the angiotensin converting enzyme 2 (ACE2) rs879922, glucose-6-phosphate dehydrogenase (G6PD) rs1050828, and tenomodulin (TNMD) rs4828038 single nucleotide polymorphisms (SNPs), and preeclampsia. A total of 356 Han Chinese pregnant women (170 controls and 186 cases) were recruited into the study. ACE2 rs879922, G6PD rs1050828, and TNMD rs4828038 were tested by the targeted next-generation sequencing technology and the data were analyzed using SPSS version 18. Genotyping of results revealed that patients with the CC/CT genotype in SNP rs4828038 or CC/CG genotype in SNP rs879922 had a significantly decreased susceptibility to late-onset preeclampsia (CC/CT versus TT: OR = 0.543, 95% CI = 0.378 to 0.779, p = .001; CC/CG versus GG: OR = 0.510, 95% CI = 0.038 to 0.860, p = .012). Our study found that the polymorphisms TNMD rs4828038 and ACE2 rs879922 might be associated with late-onset preeclampsia.IMPACT STATEMENTWhat is already known on this subject? Preeclampsia is associated with multiple SNPs, and ACE2 rs879922, G6PD rs1050828, and TNMD rs4828038 are related to essential hypertension and glucose and lipid metabolism disorders. Essential hypertension, diabetes, and dyslipidemia are risks for preeclampsia. The associations between those three SNPs and preeclampsia have not been reported.What do the results of this study add? The polymorphisms of TNMD rs4828038 and ACE2 rs879922 might be associated with the risk of late-onset preeclampsia. There was no relationship between SNP rs1050828 and preeclampsia.What are the implications of these findings for clinical practice and/or further research? TNMD rs4828038 and ACE2 rs879922 might be target sites for genetic diagnosis and therapy, and the levels of mRNA and protein in pregnant women with preeclampsia should be further tested.

COVID associated mucormycosis: A preliminary study from a dedicated COVID Hospital in Delhi

Background

It is an incontrovertible fact that the Rhino Orbital Cerebral Mucormycosis (ROCM) upsurge is being seen in the context of COVID-19 in India. Briefly presented is evidence that in patients with uncontrolled diabetes, a dysfunctional immune system due to SARS-COV-2 and injudicious use of corticosteroids may be largely responsible for this malady.

Objective

To find the possible impact of COVID 19 infection and various co-morbidities on occurrence of ROCM and demonstrate the outcome based on medical and surgical interventions.

Methodology.

Prospective longitudinal study included patients diagnosed with acute invasive fungal rhinosinusitis after a recent COVID-19 infection. Diagnostic nasal endoscopy (DNE) was performed on each patient and swabs were taken and sent for fungal KOH staining and microscopy. Medical management included Injection Liposomal Amphotericin B, Posaconazole and Voriconazole. Surgical treatment was restricted to patients with RT PCR negative results for COVID-19. Endoscopic, open, and combined approaches were utilized to eradicate infection. Follow-up for survived patients was maintained regularly for the first postoperative month.

Results

Out of total 131 patients, 111 patients had prior history of SARS COVID 19 infection, confirmed with a positive RT-PCR report and the rest 20 patients had no such history. Steroids were received as a part of treatment in 67 patients infected with COVID 19. Among 131 patients, 124 recovered, 1 worsened and 6 died. Out of 101 known diabetics, 98 recovered and 3 had fatal outcomes. 7 patients with previous history of COVID infection did not have any evidence of Diabetes mellitus, steroid intake or any other comorbidity.

Conclusion

It can be concluded that ROCM upsurge seen in the context of COVID-19 in India was mainly seen in patients with uncontrolled diabetes, a dysfunctional immune system due to SARS-COV-2 infection and injudicious use of corticosteroids.

Compliance of the POCT method with the fully automated method for HbA1c determination

Previous research suggests that point-of-care (POCT) determination of glycated hemoglobin (HbA1c) is a diagnostic test that can be an adequate alternative to measuring HbA1c in the laboratory. The main goal of this study was to examine the analytical characteristics of the novel INCLIX POCT method for HbA1c determination in order to test its performance before introducing this method into routine use. HbA1c is measured in a duplicate in 44 EDTA blood samples parallel on INCLIX POCT device (Sugitech, Inc.) and using automated turbidimetric immunoinhibition test on Olympus AU400 (Beckman Coulter). The within run imprecision was 7.58%, between runs imprecision was 6.63% and 6.22%, and day-to-day imprecision was 8.80% and 7.51%. Total laboratory imprecision was in agreement with those stated by the manufacturer. A statistically significant Pearson correlation coefficient was calculated (r = 0.871, P < 0.01; linear R2 = 0.757). Using Deming regression analysis, the following equation was obtained: y = - 1.80 + 1.304x. Our results indicate statistically significant correlation, linear relationship, and a significant degree of compatibility between the two analyzed methods. However, the negative bias of the HbA1c values determined on the POCT analyzer compared to the Olympus AU400 was confirmed, highlighting the need to standardize the INCLIX method.

Association Between Long-Term Visit-to-Visit Hemoglobin A1c and Cardiovascular Risk in Type 2 Diabetes: The ACCORD Trial

Background: To explore the association between visit-to-visit variability of glycated hemoglobin (HbA1c) and cardiovascular outcomes in the patients with type 2 diabetes mellitus (T2DM) of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study.

Methods: We conducted a post-hoc analysis on the ACCORD population including 9,544 participants with T2DM. Visit-to-visit variability of HbA1c was defined as the individual SD, coefficient of variation (CV), and variability independent of the mean (VIM) across HbA1c measurements. The clinical measurements included primary outcome [the first occurrence of non-fatal myocardial infarction (MI), non-fatal stroke or cardiovascular death], total mortality, cardiovascular death, non-fatal MI event, non-fatal stroke, total stroke, heart failure, macrovascular events, and major coronary events (CHD).

Results: Over a median follow-up of 4.85 years, 594 and 268 participants experienced all-cause mortality and cardiovascular mortality, respectively. After adjusting for baseline HbA1c levels and confounding factors, the adjusted hazard ratio (HR) comparing patients in the highest vs. the lowest quartile CV of HbA1c variability was 1.61 (95% CI 1.29–2.00) for the primary outcome. Similar trends for secondary outcome were also observed. There was no association between HbA1c fluctuation and non-fatal stroke. Noticeably, there was 66% greater risk for the all-cause mortality among patients in the highest vs. the lowest quartile (HR 1.66, 95% CI 1.27–2.17).

Conclusions: Greater variability of HbA1c is associated with higher risk for cardiovascular complications and all-cause death in T2DM. Our study stresses the significance of well-controlled glycemic levels for improving cardiovascular outcomes. Further randomized clinical trials are required to confirm these findings.

Improving Access to the Glycated Hemoglobin Test in Rural Communities With Point-of-Care Devices: An Application Study

Background: Living in a rural or remote area is frequently associated with impaired access to health services, which directly affects the possibility of early diagnosis and appropriate monitoring of diseases, mainly non-communicable ones, because of their asymptomatic onset and evolution. Point-of-care devices have emerged as useful technologies for improving access to several laboratory tests closely patients' beds or homes, which makes it possible to eliminate the distance barrier.

Objective: To evaluate the application of point-of-care technology for glycated hemoglobin (HbA1c) estimation in the assessment of glycemic control and identification of new diagnoses of diabetes in primary care among rural communities in a Brazilian municipality.

Materials and Methods: We included individuals aged 18 years or older among rural communities in a Brazilian municipality. From September 2019 to February 2020, participants were assessed for anthropometrics, blood pressure, and capillary glycemia during routine primary care team activities at health fairs and in patient groups. Participants previously diagnosed with diabetes but without recent HbA1c test results or those without a previous diagnosis but with random capillary glycemia higher than 140 mg/dL were considered positive and were tested for HbA1c by using a point-of-care device.

Results: At the end of the study, 913 individuals were accessed. Of these, 600 (65.7%) had no previous diagnosis of diabetes, 58/600 (9.7%) refused capillary glycemia screening and 542/600 (90.7%) were tested. Among tested individuals, 73/542 (13.5%) cases without a previous diagnosis of diabetes, were positive for capillary glycemia. Among positives, 31/73 (42.5%) had HbA1c levels that were considered indicative of prediabetes and 16/73 (21.9%) were newly diagnosed with diabetes. Among the participants, 313/913 (34.3%) were previously diagnosed with diabetes. Recent HbA1c results were unavailable for 210/313 (67.1%). These individuals were tested using point-of-care devices. Among them, 143/210 (68.1%) had HbA1c levels higher than target levels (>7% and >8% for adults and elderly individuals, respectively.

Conclusion: The application of point-of-care devices for HbA1c level measurement improved the access to this test for people living in rural or remote areas. Thus, it was possible to include this technology in the routine activities of primary health care teams, which increased the rates of new diagnoses and identification of patients with uncontrolled glycemia.

Factors associated with brain white matter damage in type 2 diabetes mellitus: a tract-based spatial statistics study

BACKGROUND

The pathogenesis and related factors of central nervous system abnormality in patients with type 2 diabetes mellitus (T2DM) have always been the focus of clinical research.

PURPOSE

To compare and analyze the area of white matter (WM) damage in patients with T2DM based on their level of hemoglobin A_1C (HBA_1c) and discuss any related factors.

MATERIAL AND METHODS

Based on their levels of HBA_1c, 87 patients with T2DM were divided into three groups (Group B, C, or D), of which 29 non-diabetic volunteers served as the control group (Group A). DTI data analysis was based on tract-based spatial statistics (TBSS). The obtained parameters were compared among each group and the relevant clinical factors were analyzed.

RESULTS

For age, sex, mini-mental state examination (MMSE), and Montreal Cognitive Assessment (MoCA) scores, there were no statistically significant differences among groups. For fractional anisotropy (FA) and radial diffusivity (RD) of WM, there were statistically significant differences (P < 0.05, two-tailed, FWE corrected) in the local area of corpus callosum, corona radiate, superior longitudinal fasciculus, etc. Most of these were significantly correlated with body mass index (BMI), left systolic blood pressure (SBP_L), and β₂ microglobulin.

CONCLUSION

Before the cognitive function was obviously impaired, abnormalities of FA and RD had been found in the corpus callosum, corona radiate, and upper fasciculus in patients with T2DM, which suggested that the damage mainly occurred in the myelin sheath of WM and may be related to systemic vascular damage.

Diet May Moderate the Relationship Between Arterial Stiffness and Cognitive Performance in Older Adults

BACKGROUND

Cognitive decline is influenced by various factors including diet, cardiovascular disease, and glucose control. However, the combined effect of these risk factors on cognitive performance is yet to be fully understood.

OBJECTIVE

The current study aimed to explore the inter-relationship between these risk factors and cognitive performance in older adults at risk of future cognitive decline.

METHODS

The sample comprised 163 (Age: M = 65.23 years, SD = 6.50) participants. Food Frequency Questionnaire data was used to score diet quality and adherence to the Western Style Diet (WSD) and Prudent Style Diet (PSD). Glucose control was gauged by serum levels of glycated hemoglobin (HbA1c) and arterial stiffness was measured using carotid to femoral pulse wave velocity. Cognitive performance was assessed using two subtests of the Swinburne University Computerized Cognitive Assessment Battery (SUCCAB) and Rey's Verbal Learning Test (RVLT).

RESULTS

Diet quality, adherence to the WSD or PSD, and glucose control were not significantly related to cognitive outcomes. However, a significant negative association was found between arterial stiffness and the spatial working memory subtest of SUCCAB (β= -0.21, p <  0.05). Arterial stiffness also significantly interacted with the PSD to impact total recall (F change (1,134) = 5.37, p <  0.05) and the composite score of RVLT (F change (1,134) = 4.03, p <  0.05).

CONCLUSION

In this sample of older adults at risk of cognitive decline, diet alone was not found to predict cognitive performance; however, it was found to moderate the relationship between arterial stiffness and cognition.

Functional properties of edible insects: a systematic review

Consumption of edible insects has been widely suggested as an environmentally sustainable substitute for meat to reduce GHG emissions. However, the novel research field for edible insects rely on the content of bioactive ingredients and on the ability to induce a functional effect in humans. The goal of this manuscript was to review the available body of evidence on the properties of edible insects in modulating oxidative and inflammatory stress, platelet aggregation, lipid and glucose metabolism and weight control. A search for literature investigating the functional role of edible insects was carried out in the PUBMED database using specific keywords. A total of 55 studies, meeting inclusion criteria after screening, were divided on the basis of the experimental approach: in vitro studies, cellular models/ex vivo studies or in vivo studies. In the majority of the studies, insects demonstrated the ability to reduce oxidative stress, modulate antioxidant status, restore the impaired activity of antioxidant enzymes and reduce markers of oxidative damage. Edible insects displayed anti-inflammatory activity reducing cytokines and modulating specific transcription factors. Results from animal studies suggest that edible insects can modulate lipid and glucose metabolism. The limited number of studies focused on the assessment of anticoagulation activity of edible insects make it difficult to draw conclusions. More evidence from dietary intervention studies in humans is needed to support the promising evidence from in vitro and animal models about the functional role of edible insects consumption.

The Association between Daily Total Dietary Nutrient Intake and Recent Glycemic Control States of Non-Pregnant Adults 20+ Years Old from NHANES 1999-2018 (Except for 2003-2004)

Background: Although daily total dietary nutrient intakes were potentially important factors in maintaining glycemic balance, their overall effect on glycemic control was still unclear among American adults. Objectives: We aimed to examine the association between daily total dietary nutrient intake and recent glycemic control status (RGCS). Methods: This cohort was composed of 41,302 individuals from the National Health and Nutrition Examination Survey (NHANES). The daily total intake of dietary nutrients and RGCS were independent and dependent variables, respectively. To evaluate their association, we carried out binary logistic regression, model fitting, linear discriminant analysis, and the receiver operator characteristic (ROC) analysis. Results: The result of robust check model showed that only the daily total dietary vitamin B6 intake (adjusted OR = 0.848; 95% CI: 0.738, 0.973; p-value = 0.019) was significantly negatively correlated with RGCS. When daily total dietary vitamin B6 intake and glycosylated hemoglobin (HbA1c) were used as independent variables and dependent variables, respectively, to fit the curves and lines, the established robust check model could distinguish American adults with different RGCS well. Moreover, the robust check model results of ROC analysis indicated that daily total dietary vitamin B6 intake might be a potential predictor for RGCS (AUC = 0.977; 95% CI: 0.974, 0.980; p-value < 0.001). Conclusions: This study showed that only daily total dietary vitamin B6 intake was a beneficial factor in RGCS, but it might need further multicenter or prospective studies to verify whether vitamin B6 had biological implications and public health meaning for glycemic control among American adults (specifically referred to non-pregnant participants over 20 years old).

Associations between Grip Strength and Glycemic Control in Type 2 Diabetes Mellitus: the 2014-2019 Korea National Health and Nutrition Examination Survey

OBJECTIVES

Glycemic control is essential for preventing severe complications in patients with diabetes mellitus. This study investigated the association between grip strength and glycemic control in Korean adults with type 2 diabetes mellitus.

METHODS

From the Korea National Health and Nutrition Examination Survey, 2,498 participants aged over 19 years that patients with diabetes mellitus who did not have a history of cardiovascular disease or cancer were selected for analysis. Grip strength was assessed using a handheld dynamometer and was represented as age-specific and sex-specific tertiles. Multivariable logistic regression was performed to calculate the odds ratio (OR) and 95% confidence interval (CI) of glycemic control according to the grip strength tertiles.

RESULTS

A significantly lower probability (OR, 0.67; 95% CI, 0.47 to 0.97) for glycemic control was found in the lowest tertile of grip strength compared to the highest tertile. Furthermore, a subgroup analysis by sex only found significant associations between grip strength and glycemic control in males.

CONCLUSIONS

Lower grip strength was associated with poor glycemic control in patients with diabetes mellitus, especially in males. However, further studies are needed to confirm the causal relationship between grip strength and glycemic control.

The glycemic status determines the direction of the relationship between red cell distribution width and HbA1c

AIMS

Available studies conducted on heterogenous populations on the association between the erythrocyte distribution width (RDW) and HbA1c have reported a positive, negative or neutral relationship. The aim of the present study is to investigate the debated relationship between RDW and HbA1c among hematologically healthy individuals with and without type 2 diabetes mellitus (T2DM).

METHODS

Paired measurements of RDW and HbA1c of 183 hematologically healthy individuals (100 without DM, 83 with T2DM) were obtained. The association of HbA1c with a) hematologic parameters (hemoglobin, log[ferritin], RDW) and b) factors related to glycemia (BMI, fructosamine, FPG) was examined within each group separately and in the sum of the study sample.

RESULTS

There was a significant positive correlation of RDW with HbA1c among those without DM while the opposite was true among individuals with T2DM (r = 0.315, p = 0.001 and r = -0.275, p = 0.011). In the T2DM group a significant negative correlation with fructosamine was noted (r = -0.274, p = 0.012) which was absent among normoglycemic individuals. Among those without DM the association between HbA1c and RDW remained significant after adjustment for all tested parameters. In the population with T2DM the significance was attenuated after including glycemia-related factors values. In multivariable regression in the sum of the study sample, the interaction between diabetes status and RDW as regards HbA1c was significant [unstandardized correlation coefficient - 0.397 (-0.646 to -0.147), p = 0.002] and remained significant after adjustment for multiple potential confounders.

CONCLUSIONS

Among individuals without DM, the RDW likely reflects the non-glycemic interference on HbA1c values, while in T2DM RDW may serve as an indirect index of glycemia and dysmetabolism.

Clinical assessment of W-band spectroscopy for non-invasive detection and monitoring of sustained hyperglycemia

HbA1c is the gold standard test for monitoring medium/long term glycemia conditions in diabetes care, which is a critical factor in reducing the risk of chronic diabetes complications. Current technologies for measuring HbA1c concentration are invasive and adequate assays are still limited to laboratory-based methods that are not widely available worldwide. The development of a non-invasive diagnostic tool for HbA1c concentration can lead to the decrease of the rate of undiagnosed cases and facilitate early detection in diabetes care. We present a preliminary validation diagnostic study of W-band spectroscopy for detection and monitoring of sustained hyperglycemia, using the HbA1c concentration as reference. A group of 20 patients with type 1 diabetes mellitus and 10 healthy subjects were non-invasively assessed at three different visits over a period of 7 months by a millimeter-wave spectrometer (transmission mode) operating across the full W-band. The relationship between the W-band spectral profile and the HbA1c concentration is studied using longitudinal and non-longitudinal functional data analysis methods. A potential blind discrimination between patients with or without diabetes is obtained, and more importantly, an excellent relation (R-squared = 0.97) between the non-invasive assessment and the HbA1c measure is achieved. Such results support that W-band spectroscopy has great potential for developing a non-invasive diagnostic tool for in-vivo HbA1c concentration monitoring in humans.

Search for a Functional Genetic Variant Mimicking the Effect of SGLT2 Inhibitor Treatment

SGLT2 inhibitors (SGLT2i) block renal glucose reabsorption. Due to the unexpected beneficial observations in type 2 diabetic patients potentially related to increased natriuresis, SGLT2i are also studied for heart failure treatment. This study aimed to identify genetic variants mimicking SGLT2i to further our understanding of the potential underlying biological mechanisms. Using the UK Biobank resource, we identified 264 SNPs located in the SLC5A2 gene or within 25kb of the 5′ and 3′ flanking regions, of which 91 had minor allele frequencies >1%. Twenty-seven SNPs were associated with glycated hemoglobin (HbA1c) after Bonferroni correction in participants without diabetes, while none of the SNPs were associated with sodium excretion. We investigated whether these variants had a directionally consistent effect on sodium excretion, HbA1c levels, and SLC5A2 expression. None of the variants met these criteria. Likewise, we identified no common missense variants, and although four SNPs could be defined as 5′ or 3′ prime untranslated region variants of which rs45612043 was predicted to be deleterious, these SNPs were not annotated to SLC5A2. In conclusion, no genetic variant was found mimicking SGLT2i based on their location near SLC5A2 and their association with sodium excretion or HbA1c and SLC5A2 expression or function.

Role of handgrip strength in predicting new-onset diabetes: findings from the survey of health, ageing and retirement in Europe

BACKGROUND

Diabetes is a major concern for the global health burden. This study aimed to investigate the relationship between handgrip strength (HGS) and the risk of new-onset diabetes and to compare the predictive abilities between relative HGS and dominant HGS.

METHODS

This longitudinal study used data from the Survey of Health, Ageing and Retirement in Europe (SHARE), including 66,100 European participants aged 50 years or older free of diabetes at baseline. The Cox proportional hazard model was used to analyze the relationship between HGS and diabetes, and the Harrell's C index, net reclassification index (NRI), and integrated discrimination improvement (IDI) were calculated to evaluate the predictive abilities of different HGS expressions.

RESULTS

There were 5,661 diabetes events occurred during follow-up. Compared with individuals with lowest quartiles, the hazard ratios (95 % confidence intervals) of the 2nd-4th quartiles were 0.88 (0.81-0.94), 0.82 (0.76-0.89) and 0.85 (0.78-0.93) for dominant HGS, and 0.95 (0.88-1.02), 0.82 (0.76-0.89) and 0.60 (0.54-0.67) for relative HGS. After adding dominant HGS to an office-based risk score (including age, gender, body mass index, smoking, and hypertension), the incremental values of the Harrell's C index, NRI, IDI of relative HGS were all slightly higher than those of dominant HGS in both training and validation sets.

CONCLUSIONS

Our findings supported that HGS was an independent predictor of new-onset diabetes in the middle-aged and older European population. Moreover, relative HGS exhibited a slightly higher predictive ability than dominant HGS.

Hb A2-Calderdale [δ2(NA2)His→Asn; HBD: c.7C>A] and Misdiagnosis of Type 2 Diabetes Mellitus Due to Interference with Hb A1c When Using Cation Exchange High Performance Liquid Chromatography: A Case Report

The Hb A₂-Calderdale variant [δ2(NA2)His→Asn, HBD: c.7C>A] was described as a novel variant in 2014. However, a high performance liquid chromatography (HPLC) peak was never identified indicating that this fraction could be 'hiding' somewhere else in the chromatogram. In this case report, we present evidence that the physiochemical properties of Hb A₂-Calderdale resemble those of Hb A_1c, resulting in a coelution in variant mode on the Tosoh G8 but not the Tosoh G11. This coelution results in an overestimation of Hb A_1c and can potentially cause misdiagnosis of type 2 diabetes mellitus (T2DM).

Gestational Diabetes and Risk Assessment of Adverse Perinatal Outcomes and Newborns Early Motoric Development

Background and Objectives: The aim of this study was to analyze the presence of gestational diabetes mellitus (GDM) on maternal and fetal perinatal parameters, as well to evaluate the influence of GDM on neonatal early motoric development. Materials and Methods: In this prospective study, we evaluated 203 eligible participants that were admitted to obstetrics department for a labor. GDM was assessed by evaluation of maternal parameters, fetal parameters, as well its impact on infants early motoric development (Alberta Infant Motor Scale-AIMS). Results: Presence of GDM was significantly positively associated with: pre-pregnancy weight, obesity degree, weight at delivery, gestational weight gain (GWG), body mass index (BMI) at delivery, GWG and increased pre-pregnancy BMI, glucose levels in mother's venous blood after the delivery, positive family history for cardiovascular disease, pregnancy-related hypertension, congenital thrombophilia, drug use in pregnancy, large for gestational age (LGA), mode of delivery (Cesarean section and instrumental delivery). Likewise, GDM association was detected for tested ultrasound parameters (biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femoral length (FL)), length at birth, birth weight, newborn's head circumference, newborn's chest circumference, AIMS supination and pronation at three months, AIMS supination, pronation, sitting and standing at six months. Only Amniotic Fluid Index and AIMS supination at three months of infant's age remained significantly associated in multivariate regression model. Conclusions: The presence of significant positive association of numerous tested parameters in our study on perinatal outcomes and early motoric development, points to the necessity of establishing appropriate clinical decision-making strategies for all pregnant woman at risk and emphasize the importance of providing adequate glycaemia control options and further regular follow ups during the pregnancy.

Comparison of Turbidimetric Inhibition Immunoassay, High-Performance Liquid Chromatography, and Capillary Electrophoresis Methods for Glycated Hemoglobin Determination

OBJECTIVE

The purpose of this study was to compare the performances of and evaluate the agreement among glycated hemoglobin values analyzed by using National Glycohemoglobin Standardization Program-certified and International Federation of Clinical Chemistry-standardized analyzers.

THIS CROSS-SECTIONAL STUDY WAS CONDUCTED AT THE

Armed Forces Institute of Pathology, Department of Chemical Pathology from March 2019 to May 2019.

METHODS

Glycated hemoglobin (HbA1c) was measured in the blood specimens from 100 patients on an ADVIA 1800 by a turbidimetric inhibitory immunoassay (TINIA), Sebia instrument by electrophoresis, and Bio-Rad Variant II Turbo system by high-performance liquid chromatography (HPLC). Quantitative variables were calculated as the mean ± standard deviation (SD). Precision and method comparisons were carried out according to Clinical and Laboratory Standards Institute recommendations. The results obtained from each analyzer were compared by correlation analysis. Method comparison was done by linear regression and Bland-Altman plots using the SPSS software version 24.

RESULTS

The mean ± SD HbA1c values from TINIA, electrophoresis, and HPLC were 7.188% ± 1.89%, 7.164% ± 1.866%, and 7.160% ± 1.85%, respectively. The between-run coefficients of variation for TINIA, electrophoresis, and HPLC were 0.64%, 0.61%, and 0.60%, respectively. All 3 showed good correlation (TINIA, R2 = .994, P = .00; electrophoresis, R2 = .992, P = 0.00; and HPLC, R2 = .994, P = 0.00).

CONCLUSION

The good clinical agreements of HbA1c and strong correlations between analyzers indicate that these analyzers can be used interchangeably.

Hemoglobin Fukuoka caused unexpected hemoglobin A1c results: A case report

BACKGROUND

Glycated hemoglobin (Hb) (HbA_1c) is an indicator that is used to diagnose and monitor the treatment of diabetes. Many factors can affect the detection of HbA_1c. One of the most important of these factors is the Hb variant. Here, we report a rare Hb variant and evaluate its effect on HbA_1c.

CASE SUMMARY

A 35-year-old man was suspected of harboring an Hb variant following the measurement of HbA_1c with the Variant II Turbo 2.0 Hb detection system during a routine examination. Subsequently, we used the Arkray HA-8160 and ARCHITECT c4000 system to reanalyze HbA_1c. Finally, the Hb variant was detected with a Capillary2FP analyzer that operates on the principle of capillary electrophoresis. We also used gene sequencing to investigate the mutation site. The value of HbA_1c detected with the Variant II Turbo 2.0 system was 52.7%. However, the Arkray HA-8160 system did not display a result while the ARCHITECT c16000 system showed a result of 5.4%. The Capillary2FP analyzer did not reveal any abnormal Hb zones. However, gene sequencing identified the presence of a mutation in the Hb β2 chain [CD2(CAC>TAC), His>Tyr, HBB: c.7C>T]; the genotype was Hb Fukuoka.

CONCLUSION

Hb variants could cause abnormal HbA_1c results. For patients with Hb variants, different methods should be used to detect HbA_1c.