Standards of Medical Care in Diabetes-2016: Summary of Revisions

Cost effectiveness of different screening strategies for gestational diabetes mellitus screening: study protocol of a randomized community non-inferiority trial

BACKGROUND

There is lack of ideal and comprehensive economic evaluations of various GDM strategies. The aim of this study is to the compare efficacy and cost-effectiveness of five different methods of screening for gestational diabetes mellitus (GDM).

METHODS

This study is a randomized community non-inferiority trial among 30,000 pregnant women in five different geographic regions of Iran, who were randomly assigned to one of the five GDM screening methods. All first trimester pregnant women, seeking prenatal care in governmental health care systems, who met our eligibility criteria were enrolled. The criteria suggested by the International-Association-of-Diabetes-in-Pregnancy-Study-Group, the most intensive approach, were used as reference. We used the non-inferiority approach to compare less intensive strategies to the reference one. Along with routine prenatal standard care, all participants were scheduled to have two phases of GDM screening in first and second-trimester of pregnancy, based on five different pre-specified protocols. The screening protocol included fasting plasma glucose in the first trimester and either a one step or a two-step screening method in the second trimester of pregnancy. Pregnant women were classified in three groups based on the results: diagnosed with preexisting pre-gestational overt diabetes; gestational diabetes and non-GDM women. Each group received packages for standard-care and all participants were followed till delivery; pregnancy outcomes, quality of life and cost of health care were recorded in detail using specific standardized questionnaires. Primary outcomes were defined as % birth-weight > 90th percentile and primary cesarean section. In addition, we assessed the direct health care direct and indirect costs.

RESULTS

This study will enable us to compare the cost effectiveness of different GDM screening protocols and intervention intensity (low versus high).

CONCLUSION

Results which if needed, will also enable policy makers to optimize the national GMD strategy as a resource for enhancing GDM guidelines.Trial registration Name of the registry: Iranian Registry of Clinical Trials. Trial registration number: IRCT138707081281N1. Date of registration: 2017-02-15. URL of trial registry record: https://www.irct.ir/trial/518.

Predictors of Poor Bone Microarchitecture Assessed by Trabecular Bone Score in Postsurgical Hypoparathyroidism

CONTEXT

The effects of PTH deprivation on bone are still unclear. Our objective was to report the characteristics of patients with postsurgical hypoparathyroidism (PsH) at a specialized outpatient service and correlate their trabecular bone score (TBS) values to clinical, densitometric, and laboratory findings. A secondary objective was to evaluate the fracture rates and look for associations between these events and the collected data.

RESULTS

Eighty-two patients were enrolled, of whom 70 (85.4%) were female and 17 (20.7%) had type 2 diabetes mellitus (T2DM). The median body mass index (BMI) was 27.7 kg/m2 and the median age was 59 years. Of 68 dual-energy x-ray absorptiometry (DXA) scans obtained, osteopenia and osteoporosis were present in 32.4% and 2.9%, respectively. In all, 62 lumbar scans were analyzed by using TBS. The mean TBS value (±SD) was 1.386 ± 0.140, and 32.2% of the results were <1.310. TBS values correlated negatively with BMI (mainly > 30 kg/m2), age (mainly > 60 years), and glycemia, whereas abnormal TBS correlated with osteopenia, T2DM, low-impact fracture, and menopause. Six female patients had low-impact fractures, which were associated with a lower TBS (1.178 ± 0.065 vs. 1.404 ± 0.130 in the group without fractures; P < 0.001), older age, higher BMI, impaired renal function, abnormal glycemia, and osteopenia.

CONCLUSION

The findings suggests that known risk factors for bone loss compromise the bone microarchitecture of individuals with PsH, regardless of DXA results. Menopausal women with PsH and older patients with PsH who have osteopenia, a higher BMI, or T2DM may be candidates for a more detailed assessment by using, for example, TBS.

How Serious is the Economic Burden of Diabetes Mellitus in Hainan Province? A Study Based on "System of Health Account 2011"

INTRODUCTION

The treatment of diabetes requires extensive use of healthcare resources, resulting in high medical costs, which in turn places a heavy economic burden on society, patients and their families.

METHODS

A multi-stage stratified random sampling method was used to investigate 283 medical and health institutions in Hainan Province. The total medical expenses relating to diabetes in Hainan Province in 2016, institutional flow directions, the composition of service functions and the distribution of the healthcare costs to beneficiaries were analyzed based on the System of Health Account 2011. The STATA version 12.0 statistical software package was used to collate operation data, and SPSS software was used to carry out regression analysis on the factors affecting hospitalization costs.

RESULTS

In 2016, the total medical expenses for the treatment of diabetes in Hainan Province was 242.17 billion renminbi (RMB), of which 81.95% was spent in high-level hospitals and 14.71% was spent in medical institutions providing primary care. There was little difference between outpatient and hospitalization expenses (53.01 and 46.99%, respectively). Hospitalization accounted for 77.62% of the expenses of medical institutions providing primary care. Older patients were found to spend more on medical and drug expenditure.

CONCLUSION

The economic burden of healthcare expenses for the treatment of diabetes in Hainan Province is massive, and patient treatment is concentrated in large hospitals. It is necessary to inform patients to focus more on medical institutions that provide primary care, adjust the proportion of medical insurance reimbursement, control the cost of hospitalization and strengthen the healthcare management of middle-aged and elderly diabetic patients. Only in this way can costs be reduced and the economic burden be eased.

Explaining income-related inequalities in cardiovascular risk factors in Tunisian adults during the last decade: comparison of sensitivity analysis of logistic regression and Wagstaff decomposition analysis

BACKGROUND

It is important to quantify inequality, explain the contribution of underlying social determinants and to provide evidence to guide health policy. The aim of the study is to explain the income-related inequalities in cardiovascular risk factors in the last decade among Tunisian adults aged between 35 and 70 years old.

METHODS

We performed the analysis by applying two approaches and compared the results provided by the two methods. The methods were global sensitivity analysis (GSA) using logistic regression models and the Wagstaff decomposition analysis.

RESULTS

Results provided by the two methods found a higher risk of cardiovascular diseases and diabetes in those with high socio-economic status in 2005. Similar results were observed in 2016. In 2016, the GSA showed that education level occupied the first place on the explanatory list of factors explaining 36.1% of the adult social inequality in high cardiovascular risk, followed by the area of residence (26.2%) and income (15.1%). Based on the Wagstaff decomposition analysis, the area of residence occupied the first place and explained 40.3% followed by income and education level explaining 19.2 and 14.0% respectively. Thus, both methods found similar factors explaining inequalities (income, educational level and regional conditions) but with different rankings of importance.

CONCLUSIONS

The present study showed substantial income-related inequalities in cardiovascular risk factors and diabetes in Tunisia and provided explanations for this. Results based on two different methods similarly showed that structural disparities on income, educational level and regional conditions should be addressed in order to reduce inequalities.

An Overview of Disease Burden, Mechanism, Traditional and Non-traditional Management of Type 2 Diabetes

Diabetes is a major global health problem leading to high morbidity, mortality, and economic burden. Diabetes is connected to complex social, environmental, and behavioral factors and requires multisectoral evidence-based strategies to reduce its incidence and prevalence. Here we attempt to connect existing diabetes data with the underlying mechanism of the disease, while touching disease processes and traditional management approaches for diabetes and its complications. The major objective of this manuscript is to examine the effect of nontraditional treatment modalities, e.g. non-pharmaceutical interventions, supplements, alternative and integrative therapies etc., on diabetes. We performed an extensive literature search and review using electronic databases (PubMed and Google Scholar) to examine recent and historical diabetes statistics, the underlying mechanism of the disease, traditional treatments, remission possibility, and finally, the role of alternative therapies and supplements in its management. We found that there is no sufficient evidence to make most of the alternative therapies the first line of management and prevention approach for diabetes. Long-term and large-scale studies are needed to evaluate the safety and efficacy of alternative medicine. We feel that this review could urge other health researchers to plan comprehensive studies to examine the role of alternative or newly-identified therapies in diabetes. Also, this information can be useful for diverse health professionals and policymakers in developing and implementing evidence-based strategies.

Role of Catalase in Oxidative Stress- and Age-Associated Degenerative Diseases

Reactive species produced in the cell during normal cellular metabolism can chemically react with cellular biomolecules such as nucleic acids, proteins, and lipids, thereby causing their oxidative modifications leading to alterations in their compositions and potential damage to their cellular activities. Fortunately, cells have evolved several antioxidant defense mechanisms (as metabolites, vitamins, and enzymes) to neutralize or mitigate the harmful effect of reactive species and/or their byproducts. Any perturbation in the balance in the level of antioxidants and the reactive species results in a physiological condition called “oxidative stress.” A catalase is one of the crucial antioxidant enzymes that mitigates oxidative stress to a considerable extent by destroying cellular hydrogen peroxide to produce water and oxygen. Deficiency or malfunction of catalase is postulated to be related to the pathogenesis of many age-associated degenerative diseases like diabetes mellitus, hypertension, anemia, vitiligo, Alzheimer's disease, Parkinson's disease, bipolar disorder, cancer, and schizophrenia. Therefore, efforts are being undertaken in many laboratories to explore its use as a potential drug for the treatment of such diseases. This paper describes the direct and indirect involvement of deficiency and/or modification of catalase in the pathogenesis of some important diseases such as diabetes mellitus, Alzheimer's disease, Parkinson's disease, vitiligo, and acatalasemia. Details on the efforts exploring the potential treatment of these diseases using a catalase as a protein therapeutic agent have also been described.

'Modified STOPP-START criteria for Sri Lanka'; translating to a resource limited healthcare setting by Delphi consensus

Background

‘Screening tool of older people’s prescriptions (STOPP) and screening tool to alert to right treatment (START)’ criteria is a useful tool to assess the appropriateness of medicines among older adults. However, the original STOPP/START criteria developed in the West, may not be directly applicable to resource limited healthcare settings like Sri Lanka. Hence, we aimed to modify STOPP/START criteria (Version 2) to suit Sri Lanka.

Method

Two investigators (a clinical pharmacologist and a pharmacist) reviewed and flagged criteria that were unfeasible to Sri Lanka based on their previous research experiences on using STOPP/START version 1. A Delphi consensus methodology was conducted among six experts, including geriatricians, clinical pharmacologists, physicians and a pharmacist, to review and assess each criterion (including the ones flagged by the researchers) for suitability to Sri Lanka.

Results

Two Delphi validation rounds were conducted. A final meeting was held with the participation of all experts to resolve disagreements and to establish 100% consensus. The expert panel agreed on a list of 105 criteria, including 70 STOPP and 35 START criteria, indicating an 8% reduction in criteria compared to the original version. Modifications included complete removal (n = 11), re-wording (n = 25), splitting (n = 1) of original criteria and adding a new criterion (n = 1). Main reasons for modifications were unavailability of some medicines in the country, unavailability or inaccessibility of specific clinical information required for assessment of criteria, and adherence to treatment guidelines commonly used in the country.

Conclusion

A list of ‘Modified STOPP/START criteria for Sri Lanka’ was developed. These criteria are currently being validated through a multi-centre study.

Adenosine monophosphate-activated protein kinase-based classification of diabetes pharmacotherapy

The current classification of both diabetes and antidiabetes medication is complex, preventing a treating physician from choosing the most appropriate treatment for an individual patient, sometimes resulting in patient-drug mismatch. We propose a novel, simple systematic classification of drugs, based on their effect on adenosine monophosphate-activated protein kinase (AMPK). AMPK is the master regular of energy metabolism, an energy sensor, activated when cellular energy levels are low, resulting in activation of catabolic process, and inactivation of anabolic process, having a beneficial effect on glycemia in diabetes. This listing of drugs makes it easier for students and practitioners to analyze drug profiles and match them with patient requirements. It also facilitates choice of rational combinations, with complementary modes of action. Drugs are classified as stimulators, inhibitors, mixed action, possible action, and no action on AMPK activity. Metformin and glitazones are pure stimulators of AMPK. Incretin-based therapies have a mixed action on AMPK. Sulfonylureas either inhibit AMPK or have no effect on AMPK. Glycemic efficacy of alpha-glucosidase inhibitors, sodium glucose co-transporter-2 inhibitor, colesevelam, and bromocriptine may also involve AMPK activation, which warrants further evaluation. Berberine, salicylates, and resveratrol are newer promising agents in the management of diabetes, having well-documented evidence of AMPK stimulation medicated glycemic efficacy. Hence, AMPK-based classification of antidiabetes medications provides a holistic unifying understanding of pharmacotherapy in diabetes. This classification is flexible with a scope for inclusion of promising agents of future.

Vagal Nerve Stimulation for Glycemic Control in a Rodent Model of Type 2 Diabetes

BACKGROUND

Vagal nerve stimulation (VNS) has been reported to reduce body weight and improve sympathovagal imbalance in both basic and clinical studies. Its effects on glycemic control were however unclear. The aims of this study were to investigate the effects of VNS with various parameters on blood glucose and its possible mechanisms in rats.

METHODS

A hyperglycemic rodent model induced by glucagon was used initially to optimize the VNS parameters; then, a type 2 diabetic rodent model induced by high-fat diet combined with streptozotocin was used to validate the VNS method. The VNS electrodes were implanted at the dorsal subdiaphragmatic vagus; three subcutaneous electrodes were implanted at the chest area for recording electrocardiogram in rats induced by glucagon.

RESULTS

(1) VNS with short pulse width of 0.3 ms but not 3 ms reduced blood glucose during an oral glucose tolerance test (OGTT), with a 38.4% reduction at 15 min and 26.9% at 30 min (P < 0.05, vs. sham-VNS respectively). (2) VNS at low frequency of 5 Hz but not 14 Hz or 40 Hz reduced blood glucose during the OGTT (P < 0.05, vs. sham-VNS). (3) Intermittent VNS was more potent than continuous VNS (P < 0.01). (4) No difference was found between unilateral VNS and bilateral VNS. (5) VNS enhanced vagal activity (P = 0.005). (6) The hypoglycemic effect of VNS was blocked by glucagon-like peptide-1 (GLP-1) antagonist exendin-4.

CONCLUSIONS

VNS at 5 Hz reduces blood glucose in diabetic rats by enhancing vagal efferent activity and the release of GLP-1.

Smoking in men and women with type 2 diabetes: A qualitative gender-sensitive exploration of barriers to smoking cessation among people with type 2 diabetes

Objectives

Despite growing evidence of the impact of smoking on diabetes complications, people with type 2 diabetes still smoke at high rates and little is known about the specific barriers to quit smoking in this group. The purpose of this article is to explore the perception of smoking, and motivation and barriers to quit among smokers with type 2 diabetes. This exploratory study will help designing a smoking cessation intervention tailored to the needs of people with type 2 diabetes. We hypothesize both that living with diabetes and gender may raise additional difficulties to quit smoking.

Setting

The qualitative exploratory research included ten in-depth semi-structured individual interviews and five focus groups conducted in an Ambulatory Care University Hospital in Switzerland. The thematic analysis was conducted with a gender-sensitive focus.

Participants

Both current and former smokers recruited from the ambulatory clinic and the community took part in the qualitative interviews. We restricted the analysis to 21 current smokers only.

Results

The sample included 12 men and 9 women with type 2 diabetes, having a mean age of 59.4 years, who had diabetes for an average of 9 years with a mean HbA1c of 7.4%. We found that harmful effects of tobacco were superficially understood, and participants used several patterns of thinking to minimize the risks. The relation between tobacco and diabetes was poorly known. Readiness to change was related to personal self-image and meaningful engagement in life and social relationships. Barriers could be organized into three groups: dependence, psychological habits and social barriers. Barriers were markedly shaped by gender and living with diabetes.

Conclusions

Results suggest that “one -fits-all” smoking cessation interventions do not satisfy the needs of type 2 diabetic smokers. Personalized smoking cessation interventions should be preferred and should pursue positive psychological outcomes addressing contextual factors.

Initial management of diabetic ketoacidosis and prognosis according to diabetes type: a French multicentre observational retrospective study

Background

Guidelines for the management of diabetic ketoacidosis (DKA) do not consider the type of underlying diabetes. We aimed to compare the occurrence of metabolic adverse events and the recovery time for DKA according to diabetes type.

Methods

Multicentre retrospective study conducted at five adult intermediate and intensive care units in Paris and its suburbs, France. All patients admitted for DKA between 2013 and 2014 were included. Patients were grouped and compared according to the underlying type of diabetes into three groups: type 1 diabetes, type 2 or secondary diabetes, and DKA as the first presentation of diabetes. Outcomes of interest were the rate of metabolic complications (hypoglycaemia or hypokalaemia) and the recovery time.

Results

Of 122 patients, 60 (49.2%) had type 1 diabetes, 28 (22.9%) had type 2 or secondary diabetes and 34 (27.9%) presented with DKA as the first presentation of diabetes (newly diagnosed diabetes). Despite having received lower insulin doses, hypoglycaemia was more frequent in patients with type 1 diabetes (76.9%) than in patients with type 2 or secondary diabetes (50.0%) and in patients with newly diagnosed diabetes (54.6%) (p = 0.026). In contrast, hypokalaemia was more frequent in the latter group (82.4%) than in patients with type 1 diabetes (57.6%) and type 2 or secondary diabetes (51.9%) (p = 0.022). The median recovery times were not significantly different between groups.

Conclusions

Rates of metabolic complications associated with DKA treatment differ significantly according to underlying type of diabetes. Decreasing insulin dose may limit those complications. DKA treatment recommendations should take into account the type of diabetes.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0567-y) contains supplementary material, which is available to authorized users.

Prepregnancy care in women with type 1 diabetes improves HbA1c and glucose variability without worsening hypoglycaemia time and awareness: Glycaemic variability during prepregnancy care

AIMS

To evaluate the impact of a prepregnancy care (PPC) programme, beyond HbA_1c, on hypoglycaemia awareness and glycaemic variability (GV).

METHODS

Prospective pilot study. We selected women with Type 1 diabetes who initiated a PPC programme with normal hypoglycaemia awareness (n = 24). Hypoglycaemia awareness, hypoglycaemic events and GV derived from masked-continuous glucose monitoring were evaluated in the first visit and within 2 weeks after pregnancy confirmation.

RESULTS

The duration was 16.5 ± 13.0 months. HbA_1c significantly decreased (-0.8 ± 0.7; p < 0.001). The Clarke score increased (0[0-1] vs. 1[0-2] points, p = 0.164), 2 out of 24 were reclassified as having impaired awareness of hypoglycaemia and 2 presented severe hypoglycaemia. GV decreased: standard deviation (p = 0.008), coefficient of variation (p = 0.021), mean amplitude of glycaemic excursions (p = 0.007), average daily risk range (p < 0.001), J-index (p = 0.010), high blood glucose index (HBGI) (p = 0.004), continuous overall net glycaemic action (CONGA) (p = 0.018), mean of daily differences (p = 0.045) and glycaemic risk assessment diabetes equation (p = 0.012). Final HbA_1c was associated with baseline J-index, CONGA and HBGI (β = 0.535, β = 0.466, β = 0.534, respectively; p < 0.05).

CONCLUSIONS

A PPC programme improved HbA_1c as well as GV with no significant impact on hypoglycaemia awareness. Moreover, GV could help to identify women less likely to achieve glycaemic targets. Larger studies are needed to confirm these results.

Diabetic patients in Saudi Arabia: The evaluation of glycemic control measures based on emergency department utilization and the percentages of adherence to the recommended follow-ups for microvascular complications

Objectives:

To determine the association between emergency department (ED) visits, glycemic control and the quality of preventive diabetes care among diabetic patients in a Saudi community.

Methods:

This study was an observational, cross-sectional study that collected data through interview-based surveys between February and April 2017. Data were collected from 530 diabetic patients in the diabetes clinics at King Saud Medical City, the tertiary center of Riyadh, Kingdom of Saudi Arabia.

Results:

This study found statistically significant relationships (p<0.05) between ED visits and patient age, the glycated hemoglobin (HbA1c) and education level. Emergency department visits increased by 43% for each unit of increase in HbA1c (odds ratio [OR]=1.43, 95% confidence interval (CI)=1.26-1.62). Graduating from high school decreased the odds of visiting the ED by 43% (OR=0.57, 95% CI=0.34-0.94). Most of the participants were not followed for possible microvascular complications; the majority did not visit nephrology (96.2%), ophthalmology (78.3%) and neurology (97.9%) clinics within the 12 months prior to the interviews.

Conclusion:

Emergency department visits can indicate poor glycemic control in diabetic patients. Additionally, the current practices of preventive diabetes care in Saudi Arabia are not sufficient, according to the diabetic standards of care recommended by the American Diabetes Association.

A Markov decision process for modeling adverse drug reactions in medication treatment of type 2 diabetes

Type 2 diabetes has an increasing prevalence and high cost of treatment. The goal of type 2 diabetes treatment is to control patients' blood glucose level by pharmacological interventions and to prevent adverse disease-related complications. Therefore, it is important to optimize the medication treatment plans for type 2 diabetes patients to enhance the quality of their lives and to decrease the economic burden of this chronic disease. Since the treatment of type 2 diabetes relies on medication, it is vital to consider adverse drug reactions. Adverse drug reaction is undesired harmful reactions that may result from some certain medications. Therefore, a Markov decision process is developed in this article to model the medication treatment of type 2 diabetes, considering the possibility of adverse drug reaction occurring adverse drug reaction. The optimal policy of the proposed Markov decision process model is compared with clinical guidelines and existing models in the literature. Moreover, a sensitivity analysis is conducted to address the manner in which model behavior depends on model parameterization and then therapeutic insights are obtained based on the results. The satisfying results show that the model has the capability to offer an optimal treatment policy with an acceptable expected quality of life by utilizing fewer medications and provide significant implications in endocrinology and metabolism applications.

Incretins and SGLT-2i Therapy of Type 2 Diabetes – Real Life Study of Their Therapeutic and Economic Effects

Aim

Incretins [dipeptidyl peptidase-4 inhibitors (DPP-4i) and glucagon-like peptide 1 RA (GLP-1 RA)] and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) groups are now routinely used for type 2 diabetes therapy and comprise a large number of medicinal products. The long term therapeutic and economic effect of the incretins’ and SGLT-2i in real life setting is not well documented. The goal of the current study is to analyze the cost and results of incretins and SGLT-2i based therapy for type 2 diabetes in Bulgaria.

Methods

The study uses information about the changes in glycated hemoglobin (HbA1c) level from the National diabetes register for 6122 patients and cost paid by the National Health Insurance Fund (NHIF) for diabetes complications, and medicine prices.

Results

The results show that after the therapy patients achieved excellent diabetes control. There were no HbA1c values less than 6% before treatment. After the therapy, 3356 people showed values less than 7% HbA1c. It is considered very good diabetic control. The number of people with HbA1c above 8% is decreasing significantly. The number of people with values above 9% is decreasing by almost four times. HbA1c level decreases with the highest percentage for the patients treated with GLP-1 RA, followed by those treated with DPP-4i and SGLT-2i. For a year NHIF reimbursed 5.25 million BGN for incretins and SGLT-2i therapy. NHIF can save between 306 and 510 thousand BGN from incidents that have not occurred as a result of 5 years of therapy.

Conclusion

Incretins [dipeptidyl peptidase-4 inhibitors (DPP-4i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA)] and sodium-glucose linked transporter-2 inhibitors (SGLT-2i) therapy steadily decreases the HbA1c level, and risk of developing diabetic incidents is reduced to between 333 and 465 cases among 6122 treated patients. Avoided cost for therapy of diabetes incidents account for between 305 and 510 thousand BGN.

Management and control of type 2 diabetes mellitus in Lebanon: Results from the International Diabetes Management Practices Study Wave 6

BACKGROUND

Diabetes mellitus is a worldwide public health problem associated with significant complications. There is lack of data on the quality of care of patients with diabetes, specifically among the non-Western countries. Efforts have been made in Lebanon to better study the characteristics of patients with diabetes mellitus in order to improve glycemic control and prevent late-term complications.

AIM

To investigate control and therapeutic management of patients with diabetes mellitus in the current medical practice in Lebanon.

METHODS

Wave 6 of the International Diabetes Management Practice Study in Lebanon is an international and multicenter study involving selected countries.

RESULTS

Only 1 patient with type 1 diabetes and 595 patients with type 2 diabetes were included in Wave 6. Average age was around 60 years, with a mean body mass index of 30. The mean fasting serum glucose was 159.42 mg/dL, and the mean glycosylated hemoglobin (HbA1c) level was 7.98 with around 30% achieving an HbA1c target of < 7%. More patients were on oral anti-diabetic medications. Screening of diabetic complications has improved over the years. A large percentage is diagnosed with hypertension and dyslipidemia, the majority of whom were treated but only a small percentage were controlled.

CONCLUSION

Diabetes, with its associated dyslipidemia and hypertension, is still not very well controlled. Screening for diabetes complications has improved over the years. Patients need to have more proper care, and physicians need to follow diabetes guidelines, and to have a larger number of patients who have appropriate treatment of diabetes, hypertension and lipids.

Fat-to-muscle ratio is a useful index for cardiometabolic risks: A population-based observational study

Metabolic disorders are prevalent worldwide and have recently become public health problems recently. Previous studies have proposed different body composition indices for predicting future cardiovascular risks. We hypothesized an association among fat-to-muscle ratio (FMR), metabolic syndrome (MetS), hypertension (HTN), prediabetes, type 2 diabetes mellitus (DM), and cardiovascular risk in an adult population. A total of 66829 eligible subjects composed of 34182 males and 32647 females aged 20 years or older were obtained from health examinations in the Tri-Service General Hospital from 2011 to 2017. The body composition indices included fat and muscle mass measured by bioelectrical impedance analysis. A multivariable regression model was performed in a large population-based cross-sectional study. FMR was significantly associated with MetS, prediabetes, DM and HTN in all models of both genders. Based on quartile analysis, higher FMR had higher predictive ability for adverse health outcomes. The association between different definitions of MetS and the Framingham risk score was analyzed, and FMR-incorporated MetS was more useful for predicting higher Framingham risk scores than traditional definitions. FMR was a useful indicator for the presence of adverse cardiometabolic risks. Compared to traditional definition of MetS, FMR-incorporated MetS had a greater ability to predict incident cardiovascular risks. FMR seemed to be a simple and effective index for the early prevention and management of cardiometabolic events.

The Association Between Insulin Initiation and Adverse Outcomes After Hospital Discharge in Older Adults: a Population-Based Cohort Study

BACKGROUND

Starting insulin therapy in hospitalized patients may be associated with an increase in serious adverse events after discharge.

OBJECTIVE

Determine whether post-discharge risks of death and rehospitalization are higher for older hospitalized patients prescribed new insulin therapy compared with oral hypoglycemic agents (OHAs).

DESIGN

Retrospective population-based cohort study including hospital admissions in Ontario, Canada, between April 1, 2004, and Nov 30, 2013.

PATIENTS

Persons aged 66 and over discharged after a hospitalization and dispensed a prescription for insulin and/or an OHA within 7 days of discharge. We included 104,525 individuals, subcategorized into four mutually exclusive exposure groups based on anti-hyperglycemic drug use in the 7 days post-discharge and the 365 days prior to the index admission.

MAIN MEASURES

Prescriptions at discharge were categorized as new insulin (no insulin before admission), prevalent insulin (prescribed insulin before admission), new OHA(s) (no OHA or insulin before admission), and prevalent OHA (prescribed OHA only before admission) as the referent category. The primary and secondary outcomes were 30-day deaths and emergency department (ED) visits or readmissions respectively.

KEY RESULTS

Of 104,525 patients, 9.2% were initiated on insulin, 4.1% died, and 26.2% had an ED visit or readmission within 30 days of discharge. Deaths occurred in 7.14% of new insulin users, 4.86% of prevalent insulin users, 3.25% of new OHA users, and 3.45% of prevalent OHA users. After adjustment for covariates, new insulin users had a significantly higher risk of death (adjusted hazard ratio (aHR) 1.59, 95% confidence interval (CI) 1.46 to 1.74) and ED visit/readmissions (aHR 1.17, 95% CI 1.12 to 1.22) than prevalent OHA users.

CONCLUSIONS

Initiation of insulin therapy in older hospitalized patients is associated with a higher risk of death and ED visits/readmissions after discharge, highlighting a need for better transitional care of insulin-treated patients.

Molecular Concept of Diabetic Wound Healing: Effective Role of Herbal Remedies

The incidence of diabetes mellitus (DM) is on the rise, worldwide. One of the main complications in DM is delayed wound healing and it often requires amputation. Various drugs were used to treat DM but they presented with adverse effects. Often, patients failed to comply with such treatment. This opened the door for complementary and alternative medicine. In the present review, we explored the molecular concept of wound healing occurring in different stages with special emphasis to DM. We also highlighted the potential herbal products such as NF3 (Chinese 2-Herb Formula), Zicao, Jing Wan Hong ointment, Aleo vera, mixture of Adiantum capillus-veneris, Commiphora molmol, Aloe vera, and henna, Phenol-rich compound sweet gel, Jinchuang ointment, San-huang-sheng-fu (S) oil, Yi Bu A Jie extract, Astragali Radix (AR) and Rehmanniae Radix (RR), Yiqi Huayu, Tangzu yuyang ointment, Shengji Huayu recipe, Angelica sinensis, Lithospermun erythrorhison, Hippophae rhamnoides L., Curcuma longa and Momordica charantia that could be used effectively to treat DM wounds. Future clinical trials are needed for designing potential drugs which may be effective in treating DM wounds.

Pancreatic stone protein/regenerating protein is a potential biomarker for endoplasmic reticulum stress in beta cells

Endoplasmic reticulum (ER) stress in beta cells is an important pathogenic component of both type 1 and type 2 diabetes mellitus, as well as genetic forms of diabetes, especially Wolfram syndrome. However, there are currently no convenient ways to assess ER stress in beta cells, raising the need for circulating ER stress markers indicative of beta cell health. Here we show that pancreatic stone protein/regenerating protein (PSP/reg) is a potential biomarker for ER stressed beta cells. PSP/reg levels are elevated in cell culture and mouse models of Wolfram syndrome, a prototype of ER stress-induced diabetes. Moreover, PSP/reg expression is induced by the canonical chemical inducers of ER stress, tunicamycin and thapsigargin. Circulating PSP/reg levels are also increased in some patients with Wolfram syndrome. Our results therefore reveal PSP/reg as a potential biomarker for beta cells under chronic ER stress, as is the case in Wolfram syndrome.

Partial Clinical Remission of Type 1 Diabetes Mellitus in Children: Clinical Applications and Challenges with its Definitions

The honeymoon phase, or partial clinical remission (PCR) phase, of Type 1 diabetes mellitus (T1DM) is a transitory period that is marked by endogenous insulin production by surviving β cells following a diabetes diagnosis and the introduction of insulin therapy. It is a critical window in the course of the disease that has short and long-term implications for the patient, such as a significant reduction in the risk of long-term complications of T1DM. To promote long-term cardiovascular health in children with newly diagnosed T1DM, three key steps are necessary: the generation of a predictive model for non-remission, the adoption of a user-friendly monitoring tool for remission and non-remission, and the establishment of the magnitude of the early-phase cardiovascular disease risk in these children in objective terms through changes in lipid profile. However, only about 50% of children diagnosed with T1DM experience the honeymoon phase. Accurate and prompt detection of the honeymoon phase has been hampered by the lack of an objective and easily applicable predictive model for its detection at the time of T1DM diagnosis, the complex formulas needed to confirm and monitor PCR, and the absence of a straightforward, user-friendly tool for monitoring PCR. This literature review discusses the most up-to-date information in this field by describing an objective predictive model for non-remission, an easy tool for monitoring remission or non-remission, and objective evidence for the cardiovascular protective effect of PCR in the early phase of the disease. The goal is to present non-remission as an independent clinical entity with significantly poorer long-term prognosis than partial remission.

Accuracy and precision of four main glucometers used in a Sub-Saharan African Country: a cross-sectional study

Introduction

capillary glucose measurement using point-of-care glucometers is an essential part of diabetes care. We determined the technical accuracy, clinical accuracy and precision of commonly available glucometers against standard spectrophotometry in Cameroon.

Methods

a sample of four glucometers was selected. In the 108 diabetic and non-diabetic participants, blood glucose values obtained by glucometers were compared to the reference laboratory method to determine their technical and clinical accuracies. Precision was determined by repeated measurements using standard solutions of different concentrations.

Results

accu-Chek^® Active, CodeFree™, Mylife™ Pura™ and OneTouch^® Ultra^® 2 values had correlation coefficients of 0.96, 0.87, 0.97 and 0.94 respectively with reference values, and biases of 18.7%, 29.1%, 16.1% and 13.8% respectively. All glucometers had ≥ 95% of values located within the confidence limits except OneTouch^® Ultra^®2. Accu-Chek^® Active, CodeFree™, Mylife™ Pura™ and OneTouch^® Ultra^® 2 had 99%, 93.1%, 100% and 98.0% of values in Parke's zones A and B. The coefficients of variation of the glucometers were all below 5% at all standard concentrations, except for Accu-Chek^® Active for glucose concentrations at100 and 200mg/dL.

Conclusion

no glucometer met all the international recommendations for technical accuracy. Accu-Chek™ Active and Mylife™, Pura™ met the International Organization for Standardization 2013 recommendations for clinical accuracy based on Parke's consensus error grid analysis. All glucometers assessed except Accu-Chek^® Active showed a satisfactory level of precision at all concentrations of standard solutions used.

Influence of Treatment Intensification on A1c in Patients with Suboptimally Controlled Type 2 Diabetes After 2 Oral Antidiabetic Agents

BACKGROUND

In the United States, more than 50% of patients with type 2 diabetes mellitus (T2DM) have hemoglobin A1c (A1c) levels that fail to achieve the recommended target of < 7.0%. Of these, 30%-45% have an A1c > 9.0%, the threshold for poorly controlled T2DM per National Committee for Quality Assurance (NCQA) measures. Treatment inertia is a known challenge. However, recent treatment intensification patterns and outcomes after treatment fails 2 classes of oral antidiabetic agents (OADs) are not well understood.

OBJECTIVE

To characterize treatment intensification patterns and glycemic control outcomes in patients with A1c ≥ 7.0% on 2 OADs.

METHODS

A retrospective cohort study was conducted in patients with T2DM from a regional health plan claims dataset augmented with A1c results between January 1, 2010, and March 31, 2017. Patients were identified with an A1c ≥ 7.0% (baseline), while on 2 OADs, and whose treatment was intensified with basal/biphasic insulin (insulin), glucagon-like peptide-1 receptor antagonist (GLP-1RA), or a third OAD within 365 days after the baseline A1c ≥ 7.0%. Patients had at least 1 A1c value 60-365 days (follow-up period) after treatment intensification. The proportion of patients with an A1c < 7.0% and < 9.0% at follow-up were identified by therapeutic intensification strategy. Odds ratios for achieving A1c < 7.0% and < 9.0% were calculated.

RESULTS

1,226 patients were included in the analysis, and 33.5% of the patients had a baseline A1c ≥ 9.0%. 24% of patients received insulin; 16% received GLP-1RA; and 60% received a third OAD for the treatment intensification. Overall, 26.0% achieved A1c < 7.0% and 76.1% of patients achieved < 9.0%, with a median follow-up of 119 days. The proportion of patients intensified with insulin who had an A1c ≥ 9.0% at follow-up was 34.6% versus 53.2% at baseline (P < 0.01). The corresponding percentages for those intensified with a GLP-1RA and OAD were 21.6% versus 27.1% (P = 0.24) and 20.1% versus 27.3% (P < 0.01). After controlling for baseline characteristics, the odds ratio (95% CI) of achieving A1c < 7.0% and < 9.0% was 2.05 (1.45-2.90) for GLP-1RA and 0.92 (0.61-1.40) for OAD. The association between goal attainment and GLP-1RA versus OAD intensification was influenced by the time to the A1c follow-up and baseline A1c.

CONCLUSIONS

Treatment intensification was associated with improved glycemic control in patients after therapy failed 2 OADs. Patients with higher A1c at baseline were likely to initiate insulin, which was associated with a greater drop in A1c. GLP-1RA was associated with a higher likelihood of achieving NCQA-suggested glycemic control compared with a third OAD. However, the association varied by the follow-up period. These findings are important to health plans seeking to improve patient outcomes as reflected in high performance on NCQA diabetes quality measures by promoting effective and timely treatment intensification.

DISCLOSURES

Research funding was provided by Sanofi to the Pharmacotherapy Outcomes Research Center at the University of Utah and SelectHealth to conduct this study. Thomas, Sterling, and Johnstone are employees and stock/shareholders of Sanofi. Kim, Unni, McAdam-Marx, and Brixner are employees of the Department of Pharmacotherapy at the University of Utah. Brixner also has served as an advisory board member and presenter for Sanofi. McAdam-Marx also reports grants to the Department of Pharmacotherapy, University of Utah, from AstraZeneca and Janssen, outside of the submitted work. Olsen is employed by SelectHealth. Part of the results of this study was presented at the Academy of Managed Care & Specialty Pharmacy Annual Meeting 2018 in Boston, MA, during April 23-26, 2018.

Pubertal Lipid Levels Are Significantly Lower in Youth With Type 1 Diabetes Who Experienced Partial Clinical Remission

Importance

The physiologic changes in lipids during puberty in type 1 diabetes (T1D) are unclear because subjects in previous studies were not stratified by partial clinical remission status.

Aim

To determine the effect of partial clinical remission on lipid changes during puberty in youth with T1D.

Subjects and Methods

A retrospective cross-sectional study of 194 subjects consisting of 71 control subjects of age 12.9 ± 1.3 years and 123 subjects with T1D stratified into remitters (n = 44; age, 13.0 ± 0.8 years) and nonremitters (n = 79; age, 11.2 ± 0.6 years). Partial clinical remission was defined as insulin-dose adjusted HbA1c of ≤9. Pubertal status was determined by Tanner staging.

Results

Among the pubertal cohort, low-density lipoprotein cholesterol concentration was significantly higher in the nonremitters compared with remitters (91.1 ± 25.6 vs 77.2 ± 25.8 mg/dL, P = 0.018) and with normal-weight control subjects (91.1 ± 25.6 vs 70.4 ± 22.9 mg/dL, P = 0.009) but was similar between overweight/obese control subjects and nonremitters (89.7 ± 28.9 vs 91.1± 25.6 mg/dL, P = 0.81) and between normal-weight control subjects and remitters (70.4 ± 22.9 vs 77.2 ± 25.8 mg/dL, P = 0.39). Total cholesterol was also significantly higher in nonremitters compared with remitters (167.8 ± 30.5 vs 149.8 ± 32.1 mg/dL, P = 0.012) and with normal-weight control subjects (167.8 ± 30.5 vs 143.2 ± 30.1 mg/dL, P = 0.011) but was similar between nonremitters and overweight/obese control subjects (P = 0.098) and between remitters and normal-weight control subjects (P = 0.51). Non-high-density lipoprotein cholesterol was equally significantly higher in nonremitters compared with remitters (111.3 ± 30.1 vs 95.9 ± 29.1 mg/dL, P = 0.028) and normal-weight control subjects (111.3 ± 30.1 vs 86.2 ± 32.2 mg/dL, P = 0.028) but was similar between nonremitters and overweight/obese control subjects (P = 0.48) and between remitters vs normal-weight control subjects (P = 0.39).

Conclusions

Puberty-related reductions in low-density lipoprotein, total cholesterol, and non-high-density lipoprotein occur in remitters and normal-weight control subjects but not in nonremitters and overweight/obese control subjects.

First trimester prediction of gestational diabetes mellitus using plasma biomarkers: a case-control study

Objectives To evaluate the first trimester maternal biomarkers for early pregnancy prediction of gestational diabetes mellitus (GDM). Methods The study was a case-control study of healthy women with singleton pregnancies at the first trimester carried out at the Obstetrics and Gynecology Unit, Clinica Davila, Santiago, Chile. After obtaining informed consent, peripheral blood samples of pregnant women under 14 weeks of gestation were collected. At 24-28 weeks of pregnancy, women were classified as GDM (n=16) or controls (n=80) based on the results of a 75-g oral glucose tolerance test (OGTT). In all women, we measured concentrations of fasting blood glucose, insulin, glycated hemoglobin, uric acid, cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), very low density lipoprotein (VLDL), triglycerides, aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-glutamyl transpeptidase (GGT), alkaline phosphatase (AP), sex hormone-binding globulin (SHBG), adiponectin, tissue plasminogen activator (t-PA), leptin and placental growth factor (PGF). Results The GDM group displayed an increased median concentration of cholesterol (P=0.04), triglycerides (P=0.003), insulin (P=0.003), t-PA (P=0.0088) and homeostatic model assessment (HOMA) (P=0.003) and an increased mean concentration of LDL (P=0.009) when compared to the control group. The receiver operating characteristic (ROC) curve for significant variables achieved an area under the curve (AUC) of 0.870, a sensitivity of 81.4% and a specificity of 80.0%. The OGTT was positive for GDM according to the IADPSG (International Diabetes in Pregnancy Study Group) criteria. Conclusion Women who subsequently developed GDM showed higher levels of blood-borne biomarkers during the first trimester, compared to women who did not develop GDM. These data warrant validation in a larger cohort.

Glucagon-like peptide-1 receptor agonists and pancreatic cancer: a meta-analysis with trial sequential analysis

We aimed to assess if GLP-1 agonists are associated with pancreatic cancer. Systematic review and meta-analysis of randomized trials with GLP-1 agonists as an intervention was performed. Trial sequential analysis (TSA) was performed to assess if the available information is sufficient to reject this association. Twelve trials met the study criteria, with a total of 36, 397 patients. GLP-1 analogues did not increase the risk for pancreatic cancer when compared to other treatments (OR 1.06; 95% CI 0.67 to 1.67; I² 14%). TSA confirmed that enough patients were randomized and again no association of the medications and pancreatic cancer was observed considering a NNH of 1000 and the short mean follow-up of the included trials (1.7 years). Larger studies with longer duration would be required to exclude a greater NNH and to aside concerns regarding possible influence of study duration and the outcome.

Visceral Adiposity Index as an Independent Marker of Subclinical Atherosclerosis in Individuals Prone to Diabetes Mellitus

Aims: The visceral adiposity index (VAI) has been proposed as an estimate of visceral adipose tissue (VAT) mass and as an indicator of VAT dysfunction. Both parameters are associated with cardiometabolic risk, including insulin resistance. In this study, we investigated whether VAI is associated with subclinical atherosclerosis in subjects who were free of cardiovascular disease but were at risk of developing diabetes mellitus.

Methods: A total of 731 adults with a median age of 47 years old without diabetes mellitus were included in this cross-sectional study. The anthropometric data, blood pressure, and lipid profiles of 398 women and 333 men were measured. All subjects underwent an oral glucose tolerance test, and carotid intima–media thickness (cIMT) was evaluated by ultrasound. Insulin resistance was estimated using the homeostatic model assessment of insulin resistance (HOMA-IR).

Results: VAI and HOMA-IR (β_st = 0.44, p < 0.0001), VAI and cIMT (β_st = 0.17, p < 0.0001), and HOMA-IR and cIMT (β_st = 0.09, p = 0.0127) were correlated with each other. After adjusting for cofounding variables, VAI is still correlated with HOMA-IR (β_st = 0.42, p < 0.0001). Furthermore, VAI (β_st = 0.07, p = 0.0392) but not HOMA-IR (β_st = 0.03, p = 0.37) was correlated with cIMT independently of other established cardiovascular risk factors.

Conclusion: The calculation of VAI may provide a better estimation of subclinical atherosclerosis than the calculation of HOMA-IR.

Helicobacter pylori infection increases risk of incident metabolic syndrome and diabetes: A cohort study

Emerging studies have shed light on the association between Helicobacter pylori (HP) infection and cardiometabolic risk. However, there is no evidence to support a causal link for the relationship in the general population. Our aim was to determine whether HP infection is associated with the risks of incident type II diabetes mellitus (DM) in a population-based cohort consisting of adults from the general population. A total of 69235 adults enrolled in the study obtained health examinations at the Tri-Service General Hospital in Taiwan from 2010 to 2016. HP infection detection was performed by rapid urease tests (RUTs), and endoscopic examinations were used to diagnose gastroesophageal reflux disease (GERD), gastric ulcers (GUs) and duodenal ulcers (DUs). Cross-sectional and longitudinal analyses were performed to examine the association between HP infection and cardiometabolic diseases using logistic regression and Cox regression in a large population-based study. HP infection was significantly associated with the presence of metabolic syndrome (MetS) (OR = 1.26, 95%CI: 1.00-1.57) and DM (OR = 1.59, 95%CI: 1.17-2.17) only in male subjects, and abnormal endoscopic findings were also correlated with cardiometabolic diseases. Our findings demonstrated that participants with HP infection had an elevated risk of developing incident DM (HR = 1.54, 95%CI: 1.11-2.13). In addition, endoscopic findings of a DU (HR = 1.63, 95%CI: 1.02-2.63), rather than GERD or a GU, were also predictive of incident DM. In this cohort, HP infection was a statistically significant predictor of incident DM among male population.

Highly Selective and Potent Human β-Secretase 2 (BACE2) Inhibitors against Type 2 Diabetes: Design, Synthesis, X-ray Structure and Structure-Activity Relationship Studies

Herein we present the design, synthesis, and biological evaluation of potent and highly selective β-secretase 2 (memapsin 1, beta-site amyloid precursor protein cleaving enzyme 2, or BACE 2) inhibitors. BACE2 has been recognized as an exciting new target for type 2 diabetes. The X-ray structure of BACE1 bound to inhibitor 2 a {N³ -[(1S,2R)-1-benzyl-2-hydroxy-3-[[(1S,2S)-2-hydroxy-1-(isobutylcarbamoyl)propyl]amino]propyl]-5-[methyl(methylsulfonyl)amino]-N¹ -[(1R)-1-phenylpropyl]benzene-1,3-dicarboxamide} containing a hydroxyethylamine isostere was determined. Based on this structure, a computational docking study was performed which led to inhibitor 2 a-bound BACE2 models. These were used to optimize the potency and selectivity of inhibitors. A systematic structure-activity relationship study led to the identification of determinants of the inhibitors' potency and selectivity toward the BACE2 enzyme. Inhibitors 2 d [N³ -[(1S,2R)-1-benzyl-2-hydroxy-3-[[(1S,2S)-2-hydroxy-1-(isobutylcarbamoyl)pentyl]amino]propyl]-N¹ -methyl-N¹ -[(1R)-1-phenylpropyl]benzene-1,3-dicarboxamide; K_i =0.031 nm, selectivity over BACE1: ≈174 000-fold] and 3 l [N¹ -((2S,3R)-3-hydroxy-1-phenyl-4-((3-(trifluoromethyl)benzyl)amino)butan-2-yl)-N³ ,5-dimethyl-N³ -((R)-1-phenylethyl)isophthalamide; K_i =1.6 nm, selectivity over BACE1: >500-fold] displayed outstanding potency and selectivity. Inhibitor 3 l is nonpeptide in nature and may pave the way to the development of a new class of potent and selective BACE2 inhibitors with clinical potential.

The effect of individual and mixed rewards on diabetes management: A feasibility randomized controlled trial

Background: Incentives play a role in introducing health-related benefits, but no interventions using mixed incentives, i.e. a combination of individual and group incentives, have been tested in individuals with type 2 diabetes mellitus (T2DM). We evaluated the feasibility of implementing individual- and mixed-incentives, with and without a supportive partner, on glycated haemoglobin (HbA1c) control and weight loss among patients with T2DM. Methods: This is a feasibility, sex-stratified, single-blinded, randomized controlled study in individuals with T2DM. All participants received diabetes education and tailored goal setting for weight and glycated haemoglobin (HbA1c). Participants were randomly assigned into three arms: individual incentives (Arm 1), mixed incentives-altruism (Arm 2), and mixed incentives-cooperation (Arm 3). Participants were accompanied by a diabetes educator every other week to monitor targets, and the intervention period lasted 3 months. The primary outcome was the change in HbA1c at 3 months from baseline. Weight and change body mass index (BMI) were considered as secondary outcomes. Results: Out of 783 patients screened, a total of 54 participants, 18 per study arm, were enrolled and 44 (82%) completed the 3-month follow-up. Mean baseline HbA1c values were 8.5%, 7.9% and 8.2% in Arm 1, Arm 2, and Arm 3, respectively. At 3 months, participants in all three study arms showed reductions in HbA1c ranging from -0.9% in Arm 2 to -1.4% in Arm 1. Weight and BMI also showed reductions. Conclusions: Individual and mixed cash incentives show important reductions in HbA1c, weight and BMI in patients with type 2 diabetes mellitus after 3 months.  Recruitment and uptake of the intervention were successfully accomplished demonstrating feasibility to conduct larger effectiveness studies to test individual and mixed economic incentives for diabetes management. Registration: ClinicalTrials.gov Identifier NCT02891382.

Dietary patterns as a red flag for higher risk of eating disorders among female teenagers with and without type I diabetes mellitus : Adolescents with type I diabetes mellitus are a risk factor for eating disorders: a case-control study

BACKGROUND

Female adolescents with type I diabetes mellitus (TIDM) have an increased risk of developing eating disorders (ED) due to the dietary recommendations.

OBJECTIVE

Investigate the association between dietary intake and increased risk of ED.

METHODS

Case-control study with 50 T1DM female adolescents (11-16 years) and 100 healthy peers (CG). Measures included food frequency questionnaire (FFQ-PP), Child-EDE.12, economic and anthropometric data.

RESULTS

Comparing female adolescents with T1DM vs CG, the first had higher intake of: bread, cereal, rice, and pasta (29.7 vs 23.8%, p = 0.001), vegetables (6.5 vs 2.8%, p < 0.001), milk yogurt and cheese (9.9 vs 7.6%, p = 0.032), fat, and oils (8.2 vs 5.9%, p = 0.003), besides higher fiber intake (19.2 vs 14.7%, p = 0.006) and lower consumption of sweets (13.6 vs 30.7%, p < 0.001). No differences on ED psychopathology (Child-EDE subscales and global score) were found between groups. In unadjusted association between the ED psychopathology and dietary intake, a diet rich in fiber was significantly associated with both the global and eating concern scores. Among CG, increased intake of meat, poultry, fish, and eggs and decreased bread, cereal, rice, and pasta consumption were significantly associated with higher ED psychopathology. When BMI and age are adjusted, the association between fiber intake and ED psychopathology is no longer significant among diabetic participants; however, in the CG, this association remains.

CONCLUSIONS

The study suggests that an association between dietary intake and ED psychopathology might exist in female adolescents with and without TIDM and that careful evaluation of the dietary profile and risk of developing an ED should be considered in clinical practice.

LEVEL OF EVIDENCE

Level III, case-control study.

Insulin Clearance After Oral and Intravenous Glucose Following Gastric Bypass and Gastric Banding Weight Loss

OBJECTIVE

Hepatic insulin clearance is a significant regulator of glucose homestasis. We hypothesized that the improvement in insulin clearance rates (ICRs) under fasting conditions and in response to oral and intravenous (IV) glucose would improve similarly after Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) as a function of weight loss; the difference in ICR after oral and IV glucose stimulation will be enhanced after RYGB compared with AGB, an effect mediated by glucagon-like peptide 1 (GLP-1).

RESEARCH DESIGN AND METHODS

In study 1, the ICR was calculated under fasting condition (F-ICR), after oral glucose (O-ICR), and after an isoglycemic IV glucose clamp (IV-ICR) in individuals from an established cohort with type 2 diabetes mellitus (T2DM) before, after 10% matched weight loss, and 1 year after either RYGB (n = 22) or AGB (n = 12). In study 2, O-ICR was studied in a separate cohort of individuals with T2DM (n = 22), before and 3 months after RYGB, with and without exendin(9-39) infusion.

RESULTS

In study 1, age, BMI, T2DM duration and control, and ICR did not differ between RYGB and AGB preintervention. Weight loss at 1 year was two times greater after RYGB than after AGB (31.6 ± 5.9% vs. 16.6 ± 9.8%; P < 0.05). RYGB and AGB both significantly increased F-ICR, O-ICR, and IV-ICR at 1 year. ICR was inversely associated with insulinemia. The difference between IV-ICR and O-ICR was significantly greater after RYGB versus AGB. GLP-1 antagonism with exendin(9-39) led to an increase in O-ICR in subjects post-RYGB.

CONCLUSIONS

Weight loss increased ICR, an effect more pronounced after RYGB compared with AGB. Our data support a potential role for endogenous GLP-1 in the control of postprandial ICR after RYGB.

The role of vitamin D in perinatology. An up-to-date review

The role of vitamin D in perinatology is a subject of major interest in current medicine. There is growing evidence about the role of maternal vitamin D levels in pregnancy outcomes. The aim of this review is to summarize the current literature about the role of vitamin D in perinatology. Evidence from this review suggests associations between low levels of maternal vitamin D and higher risk of certain obstetrical complications. Vitamin D has been found to be related to preeclampsia, gestational diabetes mellitus, low birth weight, and preterm birth. The current literature supports vitamin D supplementation in pregnant women, but more high-quality data are necessary. The problem that remains is how to achieve an optimal 25-hydroxyvitamin D level. To determine the real benefits of vitamin D supplementation in pregnancy, we need high-quality trials in larger groups.

Predictive Value of Blood Glucose Range for Onset of Complications in Patients with Diabetes Mellitus Type 1

Background and aims: to develop a prognostic mathematical model for risk of microangiopathy in patients with diabetes mellitus type 1 (T1DM). Materials and methods: 62 T1DM patients were divided into 2 groups according to НвА1с level: group 1 (n=18) with НвА1с ≤ 7.0% and group 2 (n=44) with НвА1с > of 7.0%. HbA1c, Cpeptide, blood creatinine, estimated glomerular filtration rate (eGFR) CKD-EPI, first morning urinary albumin excretion (AU) were determined. Blood glucose levels were conducted by CGMS (Continuous Glucose Monitoring System). All patients were followed for 3 months. Rank correlation method was used. Results: We established the direct correlation between HbA1c the AU level ρ=0.29 (р<0.016) at the beginning and ρ=0.4 (р=0.021) after 3 months. AU level has a direct correlation with blood glucose range, at the beginning ρ=0.51 (р<0.001) and after 3 months ρ=0.48 (р=0.004) visits. We made the mathematical description of this dependence. Each additional unit of blood glucose range is accompanied by increasing an average level AU level by 0.4816 mg/l. Conclusion: our mathematical equation of dependence between AU level and blood glucose range gives the opportunities to predict diabetic kidney disease progression in T1DM patients.

Effects of the combination of metformin and exercise on glycated hemoglobin, functional capacity, lipid profile, quality of life, and body weight

Objective

To evaluate the impact of the combination of metformin and exercise on changes in glycated hemoglobin (HbA_1c), functional capacity, the lipid profile, quality of life, and weight.

Methods

Data from a 12-week cardiovascular rehabilitation program (2014–2016) were retrospectively evaluated. Metformin exposure was determined through recorded prescriptions, and average minutes of exercise per week were computed from exercise logs. The primary outcomes were changes in HbA_1c and functional capacity (6-minute walk test [6MWT]) over 12 weeks. The secondary outcomes were changes in the lipid profile, quality of life, and weight. Directed acyclic graphs were used to identify potential confounders, accounted for with multiple linear regression.

Results

The cohort comprised 403 patients (85 metformin users, 318 non-users). The average amount of exercise was 102.7±48.7 minutes/week among metformin users and 107.7±58.1 minutes/week among non-users. Although changes in HbA_1c were similar for both groups, the coefficient for the metformin–exercise interaction indicated significantly greater improvements in the 6MWT among metformin users. There were no between-group differences in any secondary outcomes.

Conclusions

The combination of metformin and exercise led to greater gains in functional capacity than exercise alone. This combination did not appear to influence the effects of either treatment on other outcomes.

The Efficacy and Mechanism of Chinese Herbal Medicine on Diabetic Kidney Disease

Diabetic kidney disease (DKD) is the most common microvascular complication of diabetes and is one of the main causes of end-stage renal disease (ESRD) in many countries. The pathological features of DKD are the hypertrophy of mesangial cells, apoptosis of podocytes, glomerular basement membrane (GBM) thickening, accumulation of extracellular matrix (ECM), glomerular sclerosis, and tubulointerstitial fibrosis. The etiology of DKD is very complicated and many factors are involved, such as genetic factors, hyperglycemia, hypertension, hyperlipidemia, abnormalities of renal hemodynamics, and metabolism of vasoactive substances. Although some achievements have been made in the exploration of the pathogenesis of DKD, the currently available clinical treatment methods are still not completely effective in preventing the progress of DKD to ESRD. CHM composed of natural products has traditionally been used for symptom relief, which may offer new insights into therapeutic development of DKD. We will summarize the progress of Chinese herbal medicine (CHM) in the treatment of DKD from two aspects. In clinical trials, the Chinese herbal formulas were efficacy and safety confirmed by the randomized controlled trials. In terms of experimental research, studies provided evidence for the efficacy of CHM from the perspectives of balancing metabolic disorders, reducing inflammatory response and oxidative stress, antifibrosis, protecting renal innate cells, and regulating microRNA and metabolism. CHM consisting of different ingredients may play a role in synergistic interactions and multiple target points in the treatment of DKD.

Predictors of first-year nonadherence and discontinuation of statins among older adults: a retrospective cohort study

AIMS

The aim of this study was to examine the level of and predictors of statin nonadherence and discontinuation among older adults.

METHODS

Among 22 340 Australians aged ≥65 years who initiated statin therapy from January 2014 to December 2015, we estimated the first-year nonadherence (proportion of days covered [PDC] <0.80) and discontinuation (≥90 days without statin coverage) rates. Predictors of nonadherence and discontinuation were examined via multivariable logistic regression. Analyses were performed separately for general beneficiaries (with a higher co-payment; n = 4841) and concessional beneficiaries (with a lower co-payment; n = 17 499).

RESULTS

During the one-year follow-up, 55.1% were nonadherent (concessional 52.6%; general beneficiaries 64.2%) and 44.7% discontinued statins (concessional 43.1%; general beneficiaries 50.4%). Among concessional beneficiaries, those aged 75-84 years and ≥85 years were more likely to discontinue than people aged 65-74 years (odds ratio 1.11, 95% confidence interval 1.04-1.19 and 1.38, 1.23-1.54, respectively). Diabetes was associated with an increased likelihood of nonadherence and discontinuation, while hypertension, angina and congestive heart failure were associated with a lower likelihood of nonadherence and discontinuation. Anxiety was associated with an increased likelihood of discontinuation, but polypharmacy (concurrent use of five or more drugs) was associated with a lower likelihood of nonadherence and discontinuation. Statin initiation by a general medical practitioner was associated with both increased likelihood of nonadherence and discontinuation. Similar predictors of nonadherence and discontinuation were identified for the general beneficiaries.

CONCLUSIONS

Among older adults prescribed statins, first-year nonadherence and discontinuation are high. Specific population subgroups such as people aged ≥85 years, those with diabetes or anxiety may require additional attention to improve statin adherence.

Prevalence of Chronic Diabetic Complications in Newly Diagnosed versus Known Type 2 Diabetic Subjects in a Sample of Alexandria Population, Egypt

BACKGROUND

In Egypt, data on the prevalence of chronic diabetic complications, which are essential for the adjustment of policies and practices related to diabetes care, are scarce. Therefore, the aim of this study was to determine the frequency of chronic complications of diabetes; namely neuropathy, Diabetic Kidney Disease (DKD), retinopathy and Peripheral Arterial Disease (PAD) in newly-diagnosed versus known type 2 diabetic patients.

SUBJECTS & METHODS

This is a cross-sectional study that is based on a previous household survey conducted on a representative sample of the population of Alexandria, Egypt. This study included 506 consecutive subjects with type 2 diabetes; 323 patients with previously known T2DM and 183 patients with newly diagnosed T2DM (discovered during the survey). For each participant, a focused history was taken. Comprehensive clinical examination was done including fundus examination, foot examination and assessment of ankle brachial index. Laboratory tests included HbAlc, lipids profile, serum creatinine and Urinary Albumin Creatinine Ratio (UACR).

RESULTS

Peripheral neuropathy was detected in 20% of the studied patients; 29.4% of known patients and 3.3% of newly diagnosed patients (p<0.001). Diabetic kidney disease was detected in 33.2% of the studied patients; 46.1% of known patients and 10.4% of newly diagnosed patients (p<0.001). Diabetic retinopathy was detected in 34.6% of the studied patients; 48.3% of known patients and 10.4% of newly diagnosed patients (p<0.001). Peripheral arterial disease was detected in 32.6% of the studied patients; 45.5% of known patients and 9.8% of newly diagnosed patients (p<0.001). In patients with known diabetes, the presence of any of the studied complications (neuropathy, diabetic kidney disease, retinopathy or PAD) was significantly associated with the presence of all other complications (p< 0.001). In patients with newly-diagnosed diabetes, the presence of diabetic kidney disease was significantly associated with the presence of retinopathy (p<0.001), with no significant association with PAD (p=0.357).

CONCLUSION

The present study confirms that a considerable proportion of people with T2DM have microvascular complications and/or PAD at the time of, and possibly years before, diagnosis. Having shown that, it is strongly recommended to apply appropriate screening strategies for subjects with diabetes at the time of diagnosis. Finally, these results should be considered as a call for action for the health care planners and providers in our region to plan for early screening for diabetes and its complications to reduce the disease burden in our community.

The Prevalence of Celiac Disease-Specific Auto-Antibodies in Type 1 Diabetes in a Moroccan Population

OBJECTIVE

We aimed to determine the prevalence of specific auto-antibodies to celiac disease (CD) in Moroccan type 1 diabetic (T1D) patients and compare the clinical and biological characteristics of seropositive and seronegative cases.

PATIENTS AND METHODS

A cross-sectional study was carried out on 276 T1D patients including 109 adults and 167 pediatric cases. The screening for CD was performed by an Elisa IgA anti-tissue transglutaminase antibody (tTGA) testing, combined with IgA quantification by nephelometry. Positive-IgA-tTGA cases were secondly tested for anti-endomysial antibodies (EMA) using an immunofluorescence technique, and the IgA deficiency cases were screened for IgG-tTGA. Patients with low positive tTGA titers underwent HLA-DQ2/DQ8 typing. Sociodemographic and clinical data of the patients were collected using a hetero-administered questionnaire. The comparison of clinical and biological data between seropositive and seronegative diabetics was done using independent T, Mann-Whitney U, chi-squared, and Fisher tests, which were considered significant if p value <0.05.

RESULTS

The prevalence of CD-specific auto-antibodies was estimated to be 9.1% (IC = 95%), with 25 positive cases in tTGA and EMA testing. Eight cases displayed low titers of IgA-tTGA, among which 4 were positive for HLA-DQ2, 1 for HLA-DQ8, and 1 for both DQ2 and DQ8. The other 2 cases had a biopsy-proven CD. Compared to seronegative patients, seropositive cases had a higher percentage of associated autoimmune disorders (16% vs. 2.4%, p=0.008), with a significant lower height Z-scores (median: -0.90 (-3.93 to 0.95) vs. -0.51 (-4.54 to 2.18), p=0.029) and a higher HbA1c level (median: 11.30% (7.31 to 16.00) vs. 9.30% (4.40 to17.31), p=0.022).

CONCLUSION

The current study gave evidence of a high prevalence of CD specific auto-antibodies in T1D population. The co-existence of these two conditions was associated with a poor glycemic control, a lower height, and other autoimmune diseases. These findings may suggest the necessity of a systematic screening of CD in T1D patients.

High burden of the metabolic syndrome and its component disorders in South Africans with psoriasis

BACKGROUND

Psoriasis is associated with cardiometabolic diseases (CMDs) in Caucasians, but no data is available from sub-Saharan populations on either CMD prevalence or psoriasis risk factors. Our aim was to investigate the prevalence of CMDs in a predominantly non-Caucasian cohort of South Africans with psoriasis and to determine the principal risk factors associated with psoriasis.

METHODS

This was a cross-sectional case-control study of adult psoriasis patients (n = 103) and controls (n = 98), comparing sociodemographic, anthropometric, clinical, and biochemical characteristics. The groups were matched for gender, ethnicity, and body mass index (BMI).

RESULTS

The prevalence of metabolic syndrome (MetS) (52.4% vs. 33.7%; P = 0.007), type 2 diabetes (T2D) (25.2% vs. 4.1%; P < 0.0001), and hypertension (70.9% vs. 46.6%; P = 0.001) were all higher in the psoriasis group. High-sensitivity CRP was higher in psoriasis patients than controls (4.70 (2.00, 10.9) vs. 2.00 (1.10, 4.80) ng/ml; P < 0.0005). Multivariable logistic regression analysis showed that severe psoriasis was independently associated with MetS (odds ratio [95% CIs]: 4.42 [1.72, 11.4]; P = 0.002), T2D (11.3 [3.07, 41.3]; P = 0.0002), and hypertension (2.48 [0.97, 6.32]; P = 0.05), whilst for psoriasis the principal risk factors were smoking (3.87 [1.97, 7.63]; P < 0.0001) and hsCRP (1.05 [1.00, 1.10]; P = 0.029), with completion of high school (0.23 [0.11, 0.48]; P < 0.0001) being protective.

CONCLUSIONS

In this population, psoriasis is characterized by a high burden of CMDs, particularly in those subjects with severe psoriasis. Inflammation plays a role in the etiology of psoriasis, whilst smoking and poor education further increase disease risk.

Treatment approach to type 2 diabetes: Past, present and future

Type 2 diabetes mellitus (DM) is a lifelong metabolic disease, characterized by hyperglycaemia which gradually leads to the development and progression of vascular complications. It is recognized as a global burden disease, with substantial consequences on human health (fatality) as well as on health-care system costs. This review focuses on the topic of historical discovery and understanding the complexity of the disease in the field of pathophysiology, as well as development of the pharmacotherapy beyond insulin. The complex interplay of insulin secretion and insulin resistance developed from previously known "ominous triumvirate" to "ominous octet" indicate the implication of multiple organs in glucose metabolism. The pharmacological approach has progressed from biguanides to a wide spectrum of medications that seem to provide a beneficial effect on the cardiovascular system. Despite this, we are still not achieving the target treatment goals. Thus, the future should bring novel antidiabetic drug classes capable of acting on several levels simultaneously. In conclusion, given the raising burden of type 2 DM, the best present strategy that could contribute the most to the reduction of morbidity and mortality should be focused on primary prevention.

Glycaemic control and hypoglycaemia benefits with insulin glargine 300 U/mL extend to people with type 2 diabetes and mild-to-moderate renal impairment

AIM

To investigate the impact of renal function on the safety and efficacy of insulin glargine 300 U/mL (Gla-300) and insulin glargine 100 U/mL (Gla-100).

MATERIALS AND METHODS

A meta-analysis was performed using pooled 6-month data from the EDITION 1, 2 and 3 trials (N = 2496). Eligible participants, aged ≥18 years with a diagnosis of type 2 diabetes (T2DM), were randomized to receive once-daily evening injections of Gla-300 or Gla-100. Pooled results were assessed by two renal function subgroups: estimated glomerular filtration rate (eGFR) <60 and ≥60 mL/min/1.73 m2 .

RESULTS

The decrease in glycated haemoglobin (HbA1c) after 6 months and the proportion of individuals with T2DM achieving HbA1c targets were similar in the Gla-300 and Gla-100 groups, for both renal function subgroups. There was a reduced risk of nocturnal (12:00-5:59 am) confirmed (≤3.9 mmol/L [≤70 mg/dL]) or severe hypoglycaemia with Gla-300 in both renal function subgroups (eGFR <60 mL/min/1.73 m2 : relative risk [RR] 0.76 [95% confidence interval {CI} 0.62-0.94] and eGFR ≥60 mL/min/1.73 m2 : RR 0.75 [95% CI 0.67-0.85]). For confirmed (≤70 mg/dL [≤3.9 mmol/L]) or severe hypoglycaemia at any time of day (24 hours) the hypoglycaemia risk was lower with Gla-300 vs Gla-100 in both the lower (RR 0.94 [95% CI 0.86-1.03]) and higher (RR 0.90 [95% CI 0.85-0.95]) eGFR subgroups.

CONCLUSIONS

Gla-300 provided similar glycaemic control to Gla-100, while indicating a reduced overall risk of confirmed (≤3.9 and <3.0 mmol/L [≤70 and <54 mg/dL]) or severe hypoglycaemia, with no significant difference between renal function subgroups.