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Denig P, Stuijt PJC. Perspectives on deprescribing in older people with type 2 diabetes and/or cardiovascular conditions: challenges from healthcare provider, patient and caregiver perspective, and interventions to support a proactive approach. Expert Rev Clin Pharmacol 2024; 17:637-654. [PMID: 39119644 DOI: 10.1080/17512433.2024.2378765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/24/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION For people with type 2 diabetes and/or cardiovascular conditions, deprescribing of glucose-lowering, blood pressure-lowering and/or lipid-lowering medication is recommended when they age, and their health status deteriorates. So far, deprescribing rates of these so-called cardiometabolic medications are low. A review of challenges and interventions addressing these challenges in this population is pertinent. AREAS COVERED We first provide an overview of relevant deprescribing recommendations. Next, we review challenges for healthcare providers (HCPs) to deprescribe cardiometabolic medication and provide insight in the patient and caregiver perspective on deprescribing. We summarize findings from research on implementing deprescribing of cardiometabolic medication and reflect on strategies to enhance deprescribing. We have used a combination of methods to search for relevant articles. EXPERT OPINION There is a need for rigorous development and evaluation of intervention strategies aimed at proactive deprescribing of cardiometabolic medication. To address challenges at different levels, these should be multifaceted interventions. All stakeholders must become aware of the relevance of deintensifying medication in this population. Education and training for HCPs and patients should support patient-centered communication and shared decision-making. Development of procedures and tools to select eligible patients and conduct targeted medication reviews are important for implementation of deprescribing in routine care.
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Affiliation(s)
- Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Ke J, Ruan X, Liu W, Liu X, Wu K, Qiu H, Wang X, Ding Y, Tan X, Li Z, Cao G. Prospective cohort studies underscore the association of abnormal glycemic measures with all-cause and cause-specific mortalities. iScience 2024; 27:110233. [PMID: 39021808 PMCID: PMC11253504 DOI: 10.1016/j.isci.2024.110233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/10/2024] [Accepted: 06/06/2024] [Indexed: 07/20/2024] Open
Abstract
The role of fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), and triglyceride-glucose index (TyG index) in predicting all-cause and cause-specific mortalities remains elusive. This study included 384,420 adults from the Shanghai cohort and the UK Biobank (UKB) cohort. After multivariable adjustment in the Cox models, FPG ≥7.0 mmol/L or HbA1c ≥ 6.5% increased the risk of all-cause mortality, FPG ≥5.6 mmol/L or HbA1c ≥ 6.5% increased CVD-related mortality, and higher or lower TyG index increased all-cause and CVD-related mortalities in the Shanghai cohort; FPG ≥5.6 mmol/L, HbA1c ≥ 5.7%, TyG index <8.31 or ≥9.08 increased the risks of all-cause, CVD-related, and cancer-related mortalities in the UKB cohort. FPG or HbA1c increased the discrimination of the conventional risk model in predicting all-cause and CVD-related mortalities in both cohorts. Thus, increased levels of FPG and HbA1c and U-shaped TyG index increase the risks of all-cause especially CVD-related mortalities.
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Affiliation(s)
- Juzhong Ke
- Center for Disease Control and Prevention of Pudong New Area, Pudong Institute of Preventive Medicine, Fudan University, Shanghai, P.R. China
| | - Xiaonan Ruan
- Center for Disease Control and Prevention of Pudong New Area, Pudong Institute of Preventive Medicine, Fudan University, Shanghai, P.R. China
| | - Wenbin Liu
- Department of Epidemiology, Second Military Medical University, Shanghai, P.R. China
- Shanghai Key Laboratory of Medical Bioprotection, Shanghai, P.R. China
- Key Laboratory of Biological Defense, Ministry of Education, Shanghai, P.R. China
| | - Xiaolin Liu
- Center for Disease Control and Prevention of Pudong New Area, Pudong Institute of Preventive Medicine, Fudan University, Shanghai, P.R. China
| | - Kang Wu
- Center for Disease Control and Prevention of Pudong New Area, Pudong Institute of Preventive Medicine, Fudan University, Shanghai, P.R. China
| | - Hua Qiu
- Center for Disease Control and Prevention of Pudong New Area, Pudong Institute of Preventive Medicine, Fudan University, Shanghai, P.R. China
| | - Xiaonan Wang
- Center for Disease Control and Prevention of Pudong New Area, Pudong Institute of Preventive Medicine, Fudan University, Shanghai, P.R. China
| | - Yibo Ding
- Department of Epidemiology, Second Military Medical University, Shanghai, P.R. China
- Shanghai Key Laboratory of Medical Bioprotection, Shanghai, P.R. China
- Key Laboratory of Biological Defense, Ministry of Education, Shanghai, P.R. China
| | - Xiaojie Tan
- Department of Epidemiology, Second Military Medical University, Shanghai, P.R. China
- Shanghai Key Laboratory of Medical Bioprotection, Shanghai, P.R. China
- Key Laboratory of Biological Defense, Ministry of Education, Shanghai, P.R. China
| | - Zhitao Li
- Center for Disease Control and Prevention of Pudong New Area, Pudong Institute of Preventive Medicine, Fudan University, Shanghai, P.R. China
| | - Guangwen Cao
- Department of Epidemiology, Second Military Medical University, Shanghai, P.R. China
- Shanghai Key Laboratory of Medical Bioprotection, Shanghai, P.R. China
- Key Laboratory of Biological Defense, Ministry of Education, Shanghai, P.R. China
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Ong J, Jang KJ, Baek SJ, Hu D, Lin V, Jang S, Thaler A, Sabbagh N, Saeed A, Kwon M, Kim JH, Lee S, Han YS, Zhao M, Sokolsky O, Lee I, Al-Aswad LA. Development of oculomics artificial intelligence for cardiovascular risk factors: A case study in fundus oculomics for HbA1c assessment and clinically relevant considerations for clinicians. Asia Pac J Ophthalmol (Phila) 2024; 13:100095. [PMID: 39209216 DOI: 10.1016/j.apjo.2024.100095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 08/19/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024] Open
Abstract
Artificial Intelligence (AI) is transforming healthcare, notably in ophthalmology, where its ability to interpret images and data can significantly enhance disease diagnosis and patient care. Recent developments in oculomics, the integration of ophthalmic features to develop biomarkers for systemic diseases, have demonstrated the potential for providing rapid, non-invasive methods of screening leading to enhance in early detection and improve healthcare quality, particularly in underserved areas. However, the widespread adoption of such AI-based technologies faces challenges primarily related to the trustworthiness of the system. We demonstrate the potential and considerations needed to develop trustworthy AI in oculomics through a pilot study for HbA1c assessment using an AI-based approach. We then discuss various challenges, considerations, and solutions that have been developed for powerful AI technologies in the past in healthcare and subsequently apply these considerations to the oculomics pilot study. Building upon the observations in the study we highlight the challenges and opportunities for advancing trustworthy AI in oculomics. Ultimately, oculomics presents as a powerful and emerging technology in ophthalmology and understanding how to optimize transparency prior to clinical adoption is of utmost importance.
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Affiliation(s)
- Joshua Ong
- Department of Ophthalmology and Visual Sciences, University of Michigan Kellogg Eye Center, Ann Arbor, MI, United States
| | - Kuk Jin Jang
- School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Seung Ju Baek
- Department of AI Convergence Engineering, Republic of Korea
| | - Dongyin Hu
- School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Vivian Lin
- School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Sooyong Jang
- School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Alexandra Thaler
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Nouran Sabbagh
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Almiqdad Saeed
- Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States; St John Eye Hospital-Jerusalem, Department of Ophthalmology, Israel
| | - Minwook Kwon
- Department of AI Convergence Engineering, Republic of Korea
| | - Jin Hyun Kim
- Department of Intelligence and Communication Engineering, Republic of Korea
| | - Seongjin Lee
- Department of AI Convergence Engineering, Republic of Korea
| | - Yong Seop Han
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Institute of Health Sciences, Republic of Korea
| | - Mingmin Zhao
- School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Oleg Sokolsky
- School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Insup Lee
- School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States.
| | - Lama A Al-Aswad
- School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, United States; Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
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He Q, Gao M, Zhou X, Wang L, Fang Y, Hu R. Association between glycated hemoglobin and risk of all-cause mortality in community patients with type 2 diabetes: A prospective cohort study. J Diabetes Investig 2024; 15:939-945. [PMID: 38470086 PMCID: PMC11215688 DOI: 10.1111/jdi.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/13/2024] Open
Abstract
AIMS/INTRODUCTION To analyze the association between HbA1c level and the risk of all-cause mortality in community patients with type 2 diabetes mellitus, and to provide a scientific basis for the management of type 2 diabetes mellitus in the community. MATERIALS AND METHODS Based on a Zhejiang rural community type 2 diabetes mellitus cohort, a total of 10,310 patients with type 2 diabetes mellitus with complete baseline and follow-up data were selected. The Cox proportional hazards regression model and the restricted cubic spline model were used to evaluate the relationship between the HbA1c level and the risk of all-cause mortality. RESULTS During a mean follow-up of 5.5 years, 971 patients died. With HbA1c levels of 6.5-7.0% as the reference, after adjusting for relevant confounding factors, the HR(95%CI) of all-cause mortality with HbA1c levels of <5.5%, 5.5-6.5%, 7.0-8.0%, 8.0-9.0%, and ≥9.0% were 1.53 (1.08-2.15), 0.97 (0.79-1.21), 1.14 (0.92-1.41), 1.44 (1.14-1.83), and 2.08 (1.68-2.58), respectively. The HbA1c level was associated with the risk of all-cause mortality in a "J-shaped" manner. The risk of all-cause mortality was lowest when the HbA1c was 6.5-7.0%, and increased significantly when the HbA1c was ≥ 8.0% and the HbA1c was < 5.5% (P < 0.05). The risk of all-cause death in the HbA1c 5.5-6.5% group and the 7.0-8.0% group was not significant compared with the reference group (P > 0.05). CONCLUSIONS The HbA1c levels were associated with the risk of all-cause mortality in type 2 diabetes mellitus in a "J-shaped" manner, a too high or a too low HbA1c level could increase the risk of death. Attention should be paid to the individual evaluation of patients and the setting of appropriate glycemic control goals.
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Affiliation(s)
- Qingfang He
- Department of Chronic Non‐Communicable Diseases Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
| | - Mingfei Gao
- Health Science CenterNingbo UniversityNingboChina
| | - Xiaoyan Zhou
- Department of Chronic Non‐Communicable Diseases Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
| | - Lixin Wang
- Department of Chronic Non‐Communicable Diseases Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
| | - Yujia Fang
- Department of Chronic Non‐Communicable Diseases Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
| | - Ruying Hu
- Department of Chronic Non‐Communicable Diseases Control and PreventionZhejiang Provincial Center for Disease Control and PreventionHangzhouChina
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Zhang Z, Yang L, Cao H. Terminal trajectory of HbA 1c for 10 years supports the HbA 1c paradox: a longitudinal study using Health and Retirement Study data. Front Endocrinol (Lausanne) 2024; 15:1383516. [PMID: 38711985 PMCID: PMC11070457 DOI: 10.3389/fendo.2024.1383516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/02/2024] [Indexed: 05/08/2024] Open
Abstract
Objectives We aimed to assess the potential time-varying associations between HbA1c and mortality, as well as the terminal trajectory of HbA1c in the elderly to reveal the underlying mechanisms. Design The design is a longitudinal study using data from the Health and Retirement Study. Setting and participants Data were from the Health and Retirement Study. A total of 10,408 participants aged ≥50 years with available HbA1c measurements at baseline (2006/2008) were included. Methods Longitudinal HbA1c measured at 2010/2012 and 2014/2016 were collected. HbA1c values measured three times for their associations with all-cause mortality were assessed using Cox regression and restricted cubic splines. HbA1c terminal trajectories over 10 years before death were analyzed using linear mixed-effect models with a backward time scale. Results Women constitute 59.6% of the participants with a mean age of 69 years, with 3,070 decedents during the follow-up (8.9 years). The mortality rate during follow-up was 29.5%. Increased mortality risk became insignificant for the highest quartile of HbA1c compared to the third quartile (aHR 1.148, 1.302, and 1.069 for a follow-up of 8.9, 6.5, and 3.2 years, respectively) with a shorter follow-up, while it became higher for the lowest quartile of HbA1c (aHR 0.986, 1.068, and 1.439 for a follow-up of 8.9, 6.5, and 3.2 years, respectively). Accordingly, for both decedents with and without diabetes, an initial increase in HbA1c was followed by an accelerating terminal decline starting 5-6 years before death. Conclusions and implications The time-varying association between HbA1c and mortality mapped to the terminal trajectory in HbA1c. High and low HbA1c may have different clinical relationships with mortality. The HbA1c paradox may be partially explained by reverse causation, namely, early manifestation of death.
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Affiliation(s)
- Zeyi Zhang
- Department of Surgical Intensive Care Unit, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Longshan Yang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Heng Cao
- Department of Surgical Intensive Care Unit, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Doucet J, Gourdy P, Meyer L, Benabdelmoumene N, Bourdel-Marchasson I. Management of Glucose-Lowering Therapy in Older Adults with Type 2 Diabetes: Challenges and Opportunities. Clin Interv Aging 2023; 18:1687-1703. [PMID: 37841649 PMCID: PMC10573466 DOI: 10.2147/cia.s423122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
The population of older adults (≥65 years) with type 2 diabetes mellitus (T2DM) is diverse, encompassing individuals with varying functional capabilities, living arrangements, concomitant medical conditions, and life expectancies. Hence, their categorization into different patient profiles (ie, good health, intermediate health, poor health) may aid in clinical decision-making when establishing glycemic goals and pharmacological treatment strategies. Further granularity in assessing each patient profile through interdisciplinary collaboration may also add precision to therapeutic and monitoring decisions. In this review, we discuss with a multidisciplinary approach how to deliver the best benefit from advanced diabetes therapies and technologies to older adults with T2DM according to each patient profile. There remain however several areas that deserve further research in older adults with T2DM, including the efficacy and safety of continuous glucose monitoring and automated insulin delivery systems, the switch to once-weekly insulin, the effectiveness of multidisciplinary care models, and the use of supported telemedicine and remote blood glucose monitoring in the oldest-old (≥85 years) who particularly require the assistance of others.
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Affiliation(s)
- Jean Doucet
- Department of Polyvalent Internal Medicine, Saint Julien Hospital, Rouen University Hospital, Rouen, France
| | - Pierre Gourdy
- Department of Diabetology, Toulouse University Hospital, Toulouse, France
- Institute of Metabolic and Cardiovascular Diseases, UMR1297 INSERM/UT3, Toulouse University, Toulouse, France
| | - Laurent Meyer
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Strasbourg, Strasbourg, France
| | - Nabil Benabdelmoumene
- Department of Internal Medicine and Geriatrics, University Hospital of Marseille, Marseille, France
| | - Isabelle Bourdel-Marchasson
- CNRS, CRMSB, UMR 5536, University of Bordeaux, Bordeaux, France
- University Hospital of Bordeaux, Bordeaux, France
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Zeng R, Zhang Y, Xu J, Kong Y, Tan J, Guo L, Zhang M. Relationship of Glycated Hemoglobin A1c with All-Cause and Cardiovascular Mortality among Patients with Hypertension. J Clin Med 2023; 12:jcm12072615. [PMID: 37048698 PMCID: PMC10095266 DOI: 10.3390/jcm12072615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/01/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023] Open
Abstract
Both low and high glycated hemoglobin A1c (HbA1c) levels are well-established causal risk factors for all-cause and cardiovascular mortality in the general population and diabetic patients. However, the relationship between HbA1c with all-cause and cardiovascular mortality among patients with hypertension is unclear. We used NHANES data from 1999 to 2014 as the basis for this population-based cohort study. Based on HbA1c levels (HbA1c > 5, HbA1c > 5.5, HbA1c > 6, HbA1c > 6.5, HbA1c > 7%), hypertensive patients were divided into five groups. An analysis of multivariable Cox proportional hazards was conducted based on hazard ratios (HRs) and respective 95% confidence intervals (CIs). The relationship between HbA1c and mortality was further explored using Kaplan–Meier survival curves, restricted cubic spline curves, and subgroup analyses. In addition, 13,508 patients with hypertension (average age 58.55 ± 15.56 years) were included in the present analysis, with 3760 (27.84%) all-cause deaths during a follow-up of 127.69 ± 57.9 months. A U-shaped relationship was found between HbA1c and all-cause and cardiovascular mortality (all p for likelihood ratio tests were 0.0001). The threshold value of HbA1c related to the lowest risk for all-cause and cardiovascular mortality was 5.3% and 5.7%, respectively. Below the threshold value, increased HbA1c levels reduced the risk of all-cause mortality (HR 0.68, 95% CI 0.51–0.90, p = 0.0078) and cardiovascular mortality (HR 0.77, 95% CI 0.57–1.05, p = 0.0969). Inversely, above the threshold value, increased HbA1c levels accelerated the risk of all-cause mortality (HR 1.14, 95% CI 1.11–1.18, p < 0.0001) and cardiovascular mortality (HR 1.22, 95% CI 1.16–1.29, p < 0.0001). In conclusion, A U-shape relationship was observed between HbA1c and all-cause and cardiovascular mortality among hypertensive patients.
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Affiliation(s)
- Ruixiang Zeng
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China; (R.Z.)
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510120, China
| | - Yuzhuo Zhang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China; (R.Z.)
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510120, China
| | - Junpeng Xu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China; (R.Z.)
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510120, China
| | - Yongjie Kong
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China; (R.Z.)
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510120, China
| | - Jiawei Tan
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China; (R.Z.)
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510120, China
| | - Liheng Guo
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China; (R.Z.)
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510120, China
| | - Minzhou Zhang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou 510405, China; (R.Z.)
- Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510120, China
- Correspondence: ; Tel.: +86-20-81887233
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Bellia C, Lombardo M, Meloni M, Della-Morte D, Bellia A, Lauro D. Diabetes and cognitive decline. Adv Clin Chem 2022; 108:37-71. [PMID: 35659061 DOI: 10.1016/bs.acc.2021.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Epidemiologic studies have documented an association between diabetes and increased risk of cognitive decline in the elderly. Based on animal model studies, several mechanisms have been proposed to explain such an association, including central insulin signaling, neurodegeneration, brain amyloidosis, and neuroinflammation. Nevertheless, the exact mechanisms in humans remain poorly defined. It is reasonable, however, that many pathways may be involved in these patients leading to cognitive impairment. A major aim of clinicians is identifying early onset of neurologic signs and symptoms in elderly diabetics to improve quality of life of those with cognitive impairment and reduce costs associated with long-term complications. Several biomarkers have been proposed to identify diabetics at higher risk of developing dementia and diagnose early stage dementia. Although biomarkers of brain amyloidosis, neurodegeneration and synaptic plasticity are commonly used to diagnose dementia, especially Alzheimer disease, their role in diabetes remains unclear. The aim of this review is to explore the molecular mechanisms linking diabetes with cognitive decline and present the most important findings on the clinical use of biomarkers for diagnosing and predicting early cognitive decline in diabetics.
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Affiliation(s)
- Chiara Bellia
- Department of Biomedicine, Neurosciences, and Advanced Diagnostics, University of Palermo, Palermo, Italy.
| | - Mauro Lombardo
- Department of Human Sciences and Quality of Life Promotion, San Raffaele Open University, Rome, Italy
| | - Marco Meloni
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - David Della-Morte
- Department of Human Sciences and Quality of Life Promotion, San Raffaele Open University, Rome, Italy; Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy; Department of Neurology and Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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Crabtree T, Ogendo JJ, Vinogradova Y, Gordon J, Idris I. Intensive glycemic control and macrovascular, microvascular, hypoglycemia complications and mortality in older (age ≥60years) or frail adults with type 2 diabetes: a systematic review and meta-analysis from randomized controlled trial and observation studies. Expert Rev Endocrinol Metab 2022; 17:255-267. [PMID: 35614863 DOI: 10.1080/17446651.2022.2079495] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/16/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Guidelines for type 2 diabetes (T2D) recommend individualized HbA1c targets to take into account patient age or frailty. We synthesized evidence from randomized controlled trials and observational studies for intensive glycemic control (HbA1c target ≤58 mmol/mol) versus standard care, in elderly (age ≥60 years) or frail adults with T2D. METHODS Searches were performed utilizing recognized terms for T2D, frailty, older age, and HbA1c control and outcomes of interest. Meta-analysis was performed where possible. Primary outcomes included all-cause mortality, severe hypoglycemia, and hospital admission rates. Vascular complications, cognitive decline, and falls/fractures were secondary outcomes. RESULTS 7,528 studies were identified of which 15 different clinical studies were selected. No difference was noted in all-cause mortality with intensive control (pooled hazard ratio 0.96, 95% confidence interval 0.90-1.03), but risk of severe hypoglycemia increased (2.45, 2.22-2.72). Intensive control was associated reductions in microvascular (0.73, 0.68-0.79) and macrovascular complications (0.84, 0.79-0.89). Outcome data for risk of hospitalization, cognition, and falls/fractures were limited. CONCLUSION Intensive glycemic control was associated with reduced rates of complications but increased severe hypoglycemia. Significant heterogeneity exists and the impact of different drug regimens is unclear. Caution is needed when setting glycemic targets in elderly or frail individuals.
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Affiliation(s)
- Thomas Crabtree
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Jael-Joy Ogendo
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Yana Vinogradova
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Jason Gordon
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Health Economic Outcomes Research, Birmingham, UK
| | - Iskandar Idris
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, NIHR, Nottingham BRC, University of Nottingham, UK
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Mannucci E. Which antidiabetic drug indications are recommended for geriatric DM patients? JOURNAL OF GERONTOLOGY AND GERIATRICS 2021. [DOI: 10.36150/2499-6564-n458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Lee S, Zhou J, Leung KSK, Wu WKK, Wong WT, Liu T, Wong ICK, Jeevaratnam K, Zhang Q, Tse G. Development of a predictive risk model for all-cause mortality in patients with diabetes in Hong Kong. BMJ Open Diabetes Res Care 2021; 9:9/1/e001950. [PMID: 34117050 PMCID: PMC8201981 DOI: 10.1136/bmjdrc-2020-001950] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 05/09/2021] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Patients with diabetes mellitus are risk of premature death. In this study, we developed a machine learning-driven predictive risk model for all-cause mortality among patients with type 2 diabetes mellitus using multiparametric approach with data from different domains. RESEARCH DESIGN AND METHODS This study used territory-wide data of patients with type 2 diabetes attending public hospitals or their associated ambulatory/outpatient facilities in Hong Kong between January 1, 2009 and December 31, 2009. The primary outcome is all-cause mortality. The association of risk variables and all-cause mortality was assessed using Cox proportional hazards models. Machine and deep learning approaches were used to improve overall survival prediction and were evaluated with fivefold cross validation method. RESULTS A total of 273 678 patients (mean age: 65.4±12.7 years, male: 48.2%, median follow-up: 142 (IQR=106-142) months) were included, with 91 155 deaths occurring on follow-up (33.3%; annualized mortality rate: 3.4%/year; 2.7 million patient-years). Multivariate Cox regression found the following significant predictors of all-cause mortality: age, male gender, baseline comorbidities, anemia, mean values of neutrophil-to-lymphocyte ratio, high-density lipoprotein-cholesterol, total cholesterol, triglyceride, HbA1c and fasting blood glucose (FBG), measures of variability of both HbA1c and FBG. The above parameters were incorporated into a score-based predictive risk model that had a c-statistic of 0.73 (95% CI 0.66 to 0.77), which was improved to 0.86 (0.81 to 0.90) and 0.87 (0.84 to 0.91) using random survival forests and deep survival learning models, respectively. CONCLUSIONS A multiparametric model incorporating variables from different domains predicted all-cause mortality accurately in type 2 diabetes mellitus. The predictive and modeling capabilities of machine/deep learning survival analysis achieved more accurate predictions.
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Affiliation(s)
- Sharen Lee
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Kowloon, Hong Kong
| | | | - William Ka Kei Wu
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wing Tak Wong
- School of Life Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Department of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Ian Chi Kei Wong
- Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Kowloon, Hong Kong
| | - Gary Tse
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong
- Department of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
- Kent and Medway Medical School, Canterbury, UK
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Lee S, Zhou J, Wong WT, Liu T, Wu WKK, Wong ICK, Zhang Q, Tse G. Glycemic and lipid variability for predicting complications and mortality in diabetes mellitus using machine learning. BMC Endocr Disord 2021; 21:94. [PMID: 33947391 PMCID: PMC8097996 DOI: 10.1186/s12902-021-00751-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/12/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Recent studies have reported that HbA1c and lipid variability is useful for risk stratification in diabetes mellitus. The present study evaluated the predictive value of the baseline, subsequent mean of at least three measurements and variability of HbA1c and lipids for adverse outcomes. METHODS This retrospective cohort study consists of type 1 and type 2 diabetic patients who were prescribed insulin at outpatient clinics of Hong Kong public hospitals, from 1st January to 31st December 2009. Standard deviation (SD) and coefficient of variation were used to measure the variability of HbA1c, total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglyceride. The primary outcome is all-cause mortality. Secondary outcomes were diabetes-related complications. RESULT The study consists of 25,186 patients (mean age = 63.0, interquartile range [IQR] of age = 15.1 years, male = 50%). HbA1c and lipid value and variability were significant predictors of all-cause mortality. Higher HbA1c and lipid variability measures were associated with increased risks of neurological, ophthalmological and renal complications, as well as incident dementia, osteoporosis, peripheral vascular disease, ischemic heart disease, atrial fibrillation and heart failure (p < 0.05). Significant association was found between hypoglycemic frequency (p < 0.0001), HbA1c (p < 0.0001) and lipid variability against baseline neutrophil-lymphocyte ratio (NLR). CONCLUSION Raised variability in HbA1c and lipid parameters are associated with an elevated risk in both diabetic complications and all-cause mortality. The association between hypoglycemic frequency, baseline NLR, and both HbA1c and lipid variability implicate a role for inflammation in mediating adverse outcomes in diabetes, but this should be explored further in future studies.
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Affiliation(s)
- Sharen Lee
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, China
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - William K K Wu
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Ian Chi Kei Wong
- Department of Pharmacology and Pharmacy, University of Hong Kong, Pokfulam, Hong Kong, China
- Medicines Optimisation Research and Education (CMORE), UCL School of Pharmacy, London, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7AL, UK
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Hong Kong, China.
| | - Gary Tse
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, China.
- Medicines Optimisation Research and Education (CMORE), UCL School of Pharmacy, London, UK.
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7AL, UK.
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Lee S, Liu T, Zhou J, Zhang Q, Wong WT, Tse G. Predictions of diabetes complications and mortality using hba1c variability: a 10-year observational cohort study. Acta Diabetol 2021; 58:171-180. [PMID: 32939583 DOI: 10.1007/s00592-020-01605-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 09/09/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Emerging evidence suggests that HbA1c variability, in addition to HbA1c itself, can be used as a predictor for mortality. The present study aims to examine the predictive power of mean HbA1c and HbA1c variability measures for diabetic complications as well as mortality. METHODS The retrospective observational study analyzed diabetic patients who were prescribed insulin at outpatient clinics of the Prince of Wales Hospital and Shatin Hospital, Hong Kong, from 1 January to 31 December, 2009. Standard deviation (SD), root mean square (RMS), and coefficient of variation were used as measures of HbA1c variability. The primary outcomes were all-cause and cardiovascular mortality. Secondary outcomes were diabetes-related complications. RESULTS The study cohort consists of 3424 patients, including 3137 patients with at least three HbA1c measurements. The low mean HbA1c subgroup had significantly shorter time-to-death for all-cause mortality (P < 0.001) but not cardiovascular mortality (P = 0.920). The high Hba1c subgroup showed shorter time-to-death for all-cause (P < 0.001) and cardiovascular mortality (P < 0.001). Mean Hba1c and Hba1c variability predicted all-cause as well as cardiovascular-specific mortality. In terms of secondary outcomes, mean HbA1c and HbA1c variability significantly predicted diabetic ketoacidosis/hyperosmolar hyperglycemic state/diabetic coma, neurological, ophthalmological, and renal complications. A significant association between dichotomized HbA1c variability and hypoglycemia frequency was found (P < 0.0001). CONCLUSION High HbA1c variability is associated with increased risk of all-cause and cardiovascular mortality, as well as diabetic complications. The association between hypoglycemic frequency, HbA1c variability, and mortality suggests that intermittent hypoglycemia resulting in poorer outcomes in diabetic patients.
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Affiliation(s)
- Sharen Lee
- Laboratory of Cardiovascular Physiology, Li Ka Shing Institute of Health Sciences, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, China.
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, 300211, People's Republic of China.
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