Population diversity of cardiovascular outcome trials and real-world patients with diabetes in a Chinese tertiary hospital

Chinese expert consensus on the management of hypertension in adults with type 2 diabetes

Both hypertension and type 2 diabetes are attributable to premature death, cardiovascular and kidney diseases with largely overlapping population. Followed the GRADE approach, this expert consensus aimed to reduce the cardiovascular and kidney death and disability due to hypertension and minimize the treatment burden in adults with type 2 diabetes. Through online survey and discussion, a multidisciplinary team comprehensively prioritized seven key guideline questions. Informed by the evidence synthesis and online discussion, the team developed 12 recommendations under the GRADE Evidence-to-decision (EtD) framework. The recommendations covered the screening of hypertension in adults diagnosed with type 2 diabetes but not hypertension and the monitoring, lifestyle interventions, and medications in those diagnosed with type 2 diabetes and hypertension.

Aspartate aminotransferase to alanine aminotransferase ratio and short-term prognosis of patients with type 2 diabetes hospitalized for heart failure

Introduction

We aimed to explore the prognostic value of the aspartate aminotransferase to alanine aminotransferase (AST/ALT) ratio in non-surgical patients with type 2 diabetes hospitalized for heart failure.

Material and methods

Using a large electronic medical record-based cohort of diabetes in China (WECODe), we gathered data on non-surgical hospitalized patients with type 2 diabetes and heart failure from 2011 to 2019. Baseline AST/ALT ratio was calculated. The primary outcomes were all-cause death within 30 days after discharge, composite cardiac events, major acute kidney injury, and major systemic infection. A multivariable Cox proportional regression model was utilized to evaluate the association between the AST/ALT ratio and outcomes.

Results

This retrospective cohort included 8,073 patients (39.4% women) with type 2 diabetes hospitalized for heart failure. The median age was 71 years. Higher AST/ALT ratio was associated with higher risks of poor endpoints (with per standard deviation increment in AST/ALT ratio, for death within 30 days after discharge: adjusted hazard ratio [HR] = 1.35, 95% confidence interval [CI], 1.21 to 1.50; for composite cardiac events: HR = 1.18, 95% CI: 1.06 to 1.31). Compared to patients in the lowest quartile for the AST/ALT ratio, those in the highest quartile have elevated risk of death within 30 days after discharge and major systemic infection (HRs [95% CIs] 1.61 [1.18 to 2.19] and 1.28 [1.06 to 1.56], respectively). Subgroup analyses and sensitivity analyses confirmed the robustness of the findings.

Conclusions

Type 2 diabetes patients hospitalized for heart failure with the AST/ALT ratio in the highest quartile face a poor short-term prognosis.

The effect of glucomannan supplementation on lipid profile in adults: a GRADE-assessed systematic review and meta-analysis

BACKGROUND

Glucomannan has been studied for various health benefits, but its effects on lipid profile in adults are not well understood. This meta-analysis aims to evaluate the impact of glucomannan supplementation on serum/plasma levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), Apo B1, Apo A1, APO-B/ A1 ratio, and LDL-C/ HDL-C in adults.

METHODS

A comprehensive search was conducted across Scopus, PubMed, Embase, and Web of Science from inception to June 2024 to identify randomized controlled trials (RCTs) assessing glucomannan supplementation on lipid profile in adults. Data were extracted and analyzed using random effects model to determine the standardized mean differences (SMDs) and 95% confidence intervals (CIs) for each biomarker.

RESULTS

Glucomannan supplementation significantly decreased TC (SMD: -3.299; 95% CI: -4.955, -1.664, P < 0.001; I 2 = 95.41%, P-heterogeneity < 0.001), LDL-C (SMD: -2.993; 95% CI: -4.958, -1.028; P = 0.006; I 2 = 95.49%, P-heterogeneity < 0.001), and Apo B1 (SMD: -2.2; 95% CI: -3.58, -0.82; P = 0.01). However, glucomannan did not alter the levels of TG (SMD: -0.119; 95% CI: -1.076, 0.837, P = 0.789; I 2 = 91.63%, P-heterogeneity < 0.001), Apo A1 (SMD: -0.48; 95% CI: -6.27, 5.32; P = 0.76), APO-B/ A1 ratio (SMD: -1.15; 95% CI: -2.91, 0.61; P = 0.11), and LDL-C/ HDL-C ratio (SMD: -2.2; 95% CI: -7.28, 2.87; P = 0.2).

CONCLUSIONS

Glucomannan supplementation has a beneficial effect on the level of TC and LDL-C.

Insights Into Metformin XR Pharmacotherapy Knowledge Among Community Pharmacists: A Cross-Sectional Study

Background

There is a little knowledge on the extent to which healthcare providers understand and accept the professional recommendations and appropriate dosing strategy regarding metformin XR.

Objectives

To evaluate UAE community pharmacists' knowledge, attitude, and practices (KAP) concerning metformin XR.

Methods

This is a cross-sectional research study conducted amongst licensed community pharmacists. The survey took place via a questionnaire and physical interviews were held. The survey used in this study included questions on demographics and questions on the participants' attitudes, knowledge and practices concerning metformin XR. The factors influencing KAP regarding metformin XR were examined via simple logistic regression analysis.

Results

Threehundred fifty-three (n = 353) participants were recruited in the study. Independent pharmacies constituted 57.5% of this study sample and 42.5% were chain pharmacies. The average knowledge score about metformin XR tablets was 42.5% with a confidence interval (CI) of 95% [37.3%, 47.4]. Better knowledge scores on metformin XR tablets was observed in respondents aged ⩾40 years (OR 2.97, 95% CI 1.63-5.4), having greater than 10 years in terms of experience (OR 2.28; 95% CI 1.25-4.16) and pharmacist graduated from Regional or international universities (OR 2.08; 95% CI 1.34-3.24). About 78% (n = 275) of the participants believed that metformin XR tablets have better efficacy and 63.2% (n = 233) indicated that metformin IR was associated with greater adverse effects.

Conclusion

This study demonstrated a distinct gap in knowledge, attitude and practice pertaining to metformin XR among community pharmacists in the UAE. The community pharmacists need to enhance their practice by receiving accurate and reliable data to support their decision-making on the prescribing of metformin XR. The implementation of novel guidelines and evidence dissemination strategies may help bridge this gap.

Four-Year Increase in Step Cadence Is Associated with Improved Cardiometabolic Health in People with a History of Prediabetes

PURPOSE

To investigate associations between 4-yr change in step cadence and markers of cardiometabolic health in people with a history of prediabetes and to explore whether these associations are modified by demographic factors.

METHODS

In this prospective cohort study, adults, with a history of prediabetes, were assessed for markers of cardiometabolic health (body mass index, waist circumference, high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], triglycerides, and glycated hemoglobin A1c [HbA1c]), and free-living stepping activity (activPAL3™) at baseline, 1 yr, and 4 yr. Brisk steps per day were defined as the number of steps accumulated at ≥100 steps per minute and slow steps per day as those accumulated at <100 steps per minute; the mean peak stepping cadence during the most active 10 minutes of the day was also derived. Generalized estimating equations examined associations between 4-yr change in step cadence and change in cardiometabolic risk factors, with interactions by sex and ethnicity.

RESULTS

Seven hundred ninety-four participants were included (age, 59.8 ± 8.9 yr; 48.7% women; 27.1% ethnic minority; total steps per day, 8445 ± 3364; brisk steps per day, 4794 ± 2865; peak 10-min step cadence, 128 ± 10 steps per minute). Beneficial associations were observed between change in brisk steps per day and change in body mass index, waist circumference, HDL-C, and HbA1c. Similar associations were found between peak 10-min step cadence and HDL-C and waist circumference. Interactions by ethnicity revealed change in brisk steps per day and change in peak 10-min step cadence had a stronger association with HbA1c in White Europeans, whereas associations between change in 10-min peak step cadence with measures of adiposity were stronger in South Asians.

CONCLUSIONS

Change in the number of daily steps accumulated at a brisk pace was associated with beneficial change in adiposity, HDL-C, and HbA1c; however, potential benefits may be dependent on ethnicity for outcomes related to HbA1c and adiposity.

Cost-effectiveness of adding ezetimibe and/or PCSK9 inhibitors to high-dose statins for secondary prevention of cardiovascular disease in Chinese adults

OBJECTIVES

The latest international guideline recommended the add-on therapy of ezetimibe and PCSK9 inhibitors in selected people for the secondary prevention of cardiovascular diseases (CVDs). However, it remains unclear whether these regimens fit the Chinese healthcare system economically.

METHODS

Based on the Chinese context, this simulation study evaluated four therapeutic strategies including the high-dose statin-only group, ezetimibe plus statin group, PCSK9 inhibitors plus statin group, and PCSK9 inhibitors plus ezetimibe plus statin group. The team developed a Markov model to estimate the incremental cost-effectiveness ratio (ICER). With each 1-yr cycle, the simulation subjects could have nonfatal cardiovascular events (stroke and/or myocardial infarction) or death (vascular or nonvascular death event) with a follow-up duration of 20 yr. Cardiovascular risk reduction was gathered from a network meta-analysis, and cost and utility data were gathered from hospital databases and published research.

RESULTS

For Chinese adults receiving high-dose statins for secondary prevention of CVDs, the ICER was US$68,910 per quality-adjusted life year (QALY) for adding PCSK9 inhibitors, US$20,242 per QALY for adding ezetimibe, US$51,552 per QALY for adding both drugs. Given a threshold of US$37,655 (three times of Chinese GDP), the probability of cost-effectiveness is 2.9 percent for adding PCSK9 inhibitors, 53.1 percent for adding ezetimibe, and 16.8 percent for adding both drugs. To meet the cost-effectiveness, an acquisition price reduction of PCSK9 inhibitors of 33.6 percent is necessary.

CONCLUSION

In Chinese adults receiving high-dose statins for the secondary prevention of CVDs, adding ezetimibe is cost-effective compared to adding PCSK9 inhibitors and adding both drugs.

Professional medical education approaches: mobilizing evidence for clinicians

Rapidly proliferating high-quality evidence supports daily decision-making in clinical practice. Continuing professional medical education links this evidence to practicing clinicians who are strongly motivated to improve the quality of their care by using the latest information. Approaches to professional education vary, and their effects depend on specific scenarios. This narrative review summarizes the main approaches for professional medical education that facilitate the mobilization of evidence for clinicians. It includes traditional learning (passive and active dissemination of educational materials, lectures, and mass media dissemination), constructivist learning (engaging in local consensus processes and education outreach visits, interfacing with local opinion leaders, conducting patient-mediated interventions, employing audit and feedback processes, and utilizing clinical decision-supporting systems), and blended learning approaches (the integration of in-person or online passive learning with active and creative learning by the learners). An optimized selection from these approaches is challenging but critical to clinicians and healthcare systems.

Risk of diabetic ketoacidosis of SGLT2 inhibitors in patients with type 2 diabetes: a systematic review and network meta-analysis of randomized controlled trials

Background: Sodium-glucose cotransporter-2 (SGLT2) inhibitors have proven to be effective in improving glycemic control in patients with type 2 diabetes mellitus (T2DM). However, the risk of diabetic ketoacidosis (DKA) in patients remains unclear. The purpose of this study is to conduct this systematic review and network meta-analysis for the risk of DKA of SGLT2 inhibitors in patients with T2DM. Methods: We searched for randomized controlled trials (RCTs) concerning SGLT2 inhibitors in patients with T2DM in PubMed, EMBASE (Ovid SP), Cochrane Central Register of Controlled Trials (Ovid SP), and ClinicalTrials.gov from inception to January 2022. The primary outcomes were the risk of DKA. We assessed the sparse network with a fixed-effect model and consistency model in a frequentist framework with a graph-theoretical method by the netmeta package in R. We assessed the evidence quality of evidence of outcomes according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Results: In total, 36 studies involving 52,264 patients were included. The network showed that there was no significant difference observed among SGLT2 inhibitors, other active antidiabetic drugs, and placebo in the risk of DKA. There was no significant difference in the DKA risk between different doses of SGLT2 inhibitors. The certainty of the evidence ranged from very low to moderate. The probabilities of rankings and P-score showed that compared to placebo, SGLT2 inhibitors might increase the risk of DKA (P-score = 0.5298). Canagliflozin might have a higher DKA risk than other SGLT2 inhibitors (P-score = 0.7388). Conclusion: Neither SGLT2 inhibitors nor other active antidiabetic drugs were associated with an increased risk of DKA compared to placebo, and the risk of DKA with SGLT2 inhibitors was not found to be dose-dependent. In addition, the use of canagliflozin was less advisable than other SGLT2 inhibitors according to the rankings and P-score. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier PROSPERO, CRD42021297081.

Benefits and harms of fibrate therapy in patients with type 2 diabetes: a systematic review and meta-analysis

PURPOSE

This systematic review aimed to evaluate the benefits and harms of fibrate therapy, alone or in combination with statins, in adult patients with type 2 diabetes (T2D).

METHODS

A comprehensive search was conducted in six databases, from inception to January 27, 2022. Clinical trials that compared fibrate therapy with other lipid-lowering interventions or placebo were included. Outcomes of interest comprised cardiovascular (CV) events, complications of T2D, metabolic profile, and adverse events. Random-effects meta-analyses were performed to estimate mean differences (MD) and risk ratios (RR), alongside 95% confidence intervals (CI).

RESULTS

A total of 25 studies were included, six comparing fibrates against statins, 11 against placebo, and eight evaluating the combination of fibrates with statins. Overall risk of bias was rated as moderate, and most outcomes rendered low confidence per GRADE approach. Fibrates showed reduction of serum triglycerides (TGs) (MD -17.81, CI -33.92 to -1.69) and a marginal increase of high-density lipoprotein cholesterol (HDL-c) (MD: 1.60, CI 0.29 to 2.90) in adults with T2D, but no differences were found in CV events when compared to statin therapy (RR 0.99, CI 0.76 to 1.09). When used in combination with statins, no major differences were exhibited regarding lipid profile and CV outcomes. Adverse events were comparable between fibrate and statin monotherapies (e.g., RR of 1.03 for rhabdomyolysis, and 0.90 for gastrointestinal events).

CONCLUSIONS

Fibrate therapy in patients with T2D results in a marginal improvement of TGs and HDL-c but without reducing the risk of CV events and mortality. Their use should be reserved for very specific scenarios after a deliberative dialogue between patients and clinicians regarding their benefits and harms.

Partial Identification of Personalized Treatment Response with Trial-reported Analyses of Binary Subgroups

Medical journals have adhered to a reporting practice that seriously limits the usefulness of published trial findings. Medical decision makers commonly observe many patient covariates and seek to use this information to personalize treatment choices. Yet standard summaries of trial findings only partition subjects into broad subgroups, typically binary categories. Given this reporting practice, we study the problem of inference on long mean treatment outcomes E[y(t)|x], where t is a treatment, y(t) is a treatment outcome, and the covariate vector x has length K, each component being a binary variable. The available data are estimates of {E[y(t)|x k = 0], E[y(t)|x k = 1], P(x k )}, k = 1,..., K reported in journal articles. We show that reported trial findings partially identify {E[y(t)|x], P(x)}. Illustrative computations demonstrate that the summaries of trial findings in journal articles may imply only wide bounds on long mean outcomes. One can realistically tighten inferences if one can combine reported trial findings with credible assumptions having identifying power, such as bounded-variation assumptions.

Efficacy, safety and immunogenicity of etanercept biosimilars versus reference biologics in patients with rheumatoid arthritis: A meta-analysis

Background: Although with the application of etanercept biosimilars in the field of rheumatoid arthritis, the evidences of their efficacy, safety, and immunogenicity are still limited. We conducted this meta-analysis to evaluate the efficacy, safety and immunogenicity of etanercept biosimilars for treating active rheumatoid arthritis compared to reference biologics (Enbrel^®). Methods: PubMed, Embase, Central, and ClinicalTrials.gov were searched for randomized controlled trials of etanercept biosimilars treated in adult patients diagnosed with rheumatoid arthritis from their earliest records to 15 August 2022. The outcomes included ACR20, ACR50, and ACR70 response rate at different time points from FAS or PPS, adverse events, and proportion of patients developed anti-drug antibodies. The risk of bias of each included study was assessed using the revised Cochrane Risk of Bias in Randomised Trials tool, and the certainty of evidence was rated according to the Grading of Recommendation Assessment, Development, and Evaluation. Results: Six RCTs with 2432 patients were included in this meta-analysis. Etanercept biosimilars showed more benefits in ACR50 at 24 weeks from PPS [5 RCTs, OR = 1.22 (1.01, 1.47), p = 0.04, I ² = 49%, high certainty], ACR50 at 1 year from PPS [3 RCTs, OR = 1.43 (1.10, 1.86), p < 0.01, I ² = 0%, high certainty] or FAS [2 RCTs, OR = 1.36 (1.04, 1.78), p = 0.03, I ² = 0%, high certainty], and ACR70 at 1 year from PPS [3 RCTs, OR = 1.32 (1.01, 1.71), p = 0.04, I ² = 0%, high certainty]. In terms of other outcomes about efficacy, safety, and immunogenicity, the results showed that there was no significant difference between etanercept biosimilars and reference biologics, and the certainty of evidences ranged from low to moderate. Conclusion: Etanercept biosimilars showed more benefits in ACR50 response rate at 1 year than reference biologics (Enbrel^®), other outcomes for clinical efficacy, safety, and immunogenicity of etanercept biosimilars were comparable with originator in patients with rheumatoid arthritis. Systematic Review Registration: PROSPERO, identifier CRD42022358709.

'Stress hyperglycemia ratio and in-hospital prognosis in non-surgical patients with heart failure and type 2 diabetes

OBJECTIVE

To evaluate the impact of stress hyperglycemia on the in-hospital prognosis in non-surgical patients with heart failure and type 2 diabetes.

RESEARCH DESIGN AND METHODS

We identified non-surgical hospitalized patients with heart failure and type 2 diabetes from a large electronic medical record-based database of diabetes in China (WECODe) from 2011 to 2019. We estimated stress hyperglycemia using the stress hyperglycemia ratio (SHR) and its equation, say admission blood glucose/[(28.7 × HbA1c)- 46.7]. The primary outcomes included the composite cardiac events (combination of death during hospitalization, requiring cardiopulmonary resuscitation, cardiogenic shock, and the new episode of acute heart failure during hospitalization), major acute kidney injury (AKI stage 2 or 3), and major systemic infection.

RESULTS

Of 2875 eligible Chinese adults, SHR showed U-shaped associations with composite cardiac events, major AKI, and major systemic infection. People with SHR in the third tertile (vs those with SHR in the second tertile) presented higher risks of composite cardiac events ([odds ratio, 95% confidence interval] 1.89, 1.26 to 2.87) and major AKI (1.86, 1.01 to 3.54). In patients with impaired kidney function at baseline, both SHR in the first and third tertiles anticipated higher risks of major AKI and major systemic infection.

CONCLUSIONS

Both high and low SHR indicates poor prognosis during hospitalization in non-surgical patients with heart failure and type 2 diabetes.

Glycated Haemoglobin A1c Variability Score Elicits Kidney Function Decline in Chinese People Living with Type 2 Diabetes

Our aim was to investigate the association of glycated haemoglobin A1c (HbA1c) variability score (HVS) with estimated glomerular filtration rate (eGFR) slope in Chinese adults living with type 2 diabetes. This cohort study included adults with type 2 diabetes attending outpatient clinics between 2011 and 2019 from a large electronic medical record-based database of diabetes in China (WECODe). We estimated the individual-level visit-to-visit HbA1c variability using HVS, a proportion of changes in HbA1c of ≥0.5% (5.5 mmol/mol). We estimated the odds of people experiencing a rapid eGFR annual decline using a logistic regression and differences across HVS categories in the mean eGFR slope using a mixed-effect model. The analysis involved 2397 individuals and a median follow-up of 4.7 years. Compared with people with HVS ≤ 20%, those with HVS of 60% to 80% had 11% higher odds of experiencing rapid eGFR annual decline, with an extra eGFR decline of 0.93 mL/min/1.73 m2 per year on average; those with HVS > 80% showed 26% higher odds of experiencing a rapid eGFR annual decline, with an extra decline of 1.83 mL/min/1.73 m2 per year on average. Chinese adults with type 2 diabetes and HVS > 60% could experience a more rapid eGFR decline.

Efficacy and safety of tirzepatide in patients with type 2 diabetes: A systematic review and meta-analysis

Purpose: A systematic review and meta-analysis was conducted to combine the data available from clinical trials and evaluate the clinical efficacy and safety of tirzepatide in people with type 2 diabetes (T2D). Methods: We systematically searched the MEDLINE, Embase, Cochrane Library, and clinical trials registries (https://clinicaltrials.gov) up to 25 March 2022 for randomized controlled trials (RCTs) that compared tirzepatide with placebo or active hypoglycemic drugs in subjects with T2D. Heterogeneity was judged by the I ² value and Cochran's Q test. The randomized effects model was adopted to calculate risk ratios and weighted mean differences (WMDs). The primary outcome was the change from baseline in HbA1c levels. Secondary efficacy endpoints were fasting serum glucose (FSG), change of body weight, blood pressure, fasting lipid profiles, and safety indexes. Results: Six trials comprising 6,579 subjects (4,410 in the tirzepatide group and 2,054 in the control group) fulfilled the pre-specified criteria and were included in the study. Tirzepatide treatment resulted in reducing HbA1c (WMD: -1.07%; 95% confidence intervals [CIs]: -1.44, -0.56), FSG (WMD, -21.50 mg/dl; 95% CI: -34.44, -8.56), body weight (WMD: -7.99 kg; 95% CI -11.36, -4.62), and blood pressure and ameliorated fasting lipid profiles, without increasing hypoglycemia, either as monotherapy or an add-on therapy. Tirzepatide increased the risk of gastrointestinal adverse events mainly in add-on therapy but not in terms of pancreatitis or cholelithiasis. Furthermore, tirzepatide presented a dose-response effect on the reduction in HbA1c and body weight and increase in nausea and vomiting. Conclusion: In patients with type 2 diabetes, tirzepatide shows superior blood glucose control and weight loss performance, without an increased risk of hypoglycemia. Systematic Review Registration: (https://www.crd.york.ac.uk/PROSPERO), identifier (CRD42022319442).

Effectiveness of clinical pharmacist-led smartphone application on medication adherence, insulin injection technique and glycemic control for women with gestational diabetes receiving multiple daily insulin injection: A randomized clinical trial

AIM

To investigate the efficacy of a clinical pharmacist-led smartphone application (app) on medication adherence, insulin injection technique (IIT) and diabetes-related outcomes among women with gestational diabetes mellitus (GDM) receiving insulin therapy.

METHOD

In all, 124 women were randomly (1:1 ratio) assigned to receive app intervention plus usual care (intervention) or usual care (control), and were followed up till 12 weeks postpartum. Interventions centralized on medication adherence and IIT. Primary outcome was medication adherence assessed by the 5-item Medication Adherence Report Scale. Secondary outcomes included IIT, insulin requirement, prepartal and puerperal glycemic control, hypoglycemia, and pregnancy and neonatal outcomes.

RESULTS

A total of 119 patients completed the follow-up evaluation (58 intervention, 61 control). Significant more women with high medication adherence in the intervention group was observed (69.0% vs. 34.4%, p = 0.000). The other notable benefits (all p < 0.05) included patient percentage with appropriate IIT, lesser preprandial insulin dose, patient proportion with both qualified prepartal FPG and 2 hPG, and puerperal FPG or HbA1c, fewer hypoglycemia, and lower neonatal intensive care unit (NICU) admission rate. Cesarean delivery rate was higher among intervention cases (p < 0.05). Qualified prepartal glycemic control was related to high medication adherence and proper IIT. NICU admission was associated with complicated with gestational hypertension, deficient medication adherence and premature rupture of fetal membrane.

CONCLUSION

Combined with usual care, clinical pharmacist-led smartphone app might be a valid tool for GDM management.

Genetically Predicted Lifelong Circulating 25(OH)D Levels are Associated With Serum Calcium Levels and Kidney Stone Risk

OBJECTIVE

To assess whether lifelong higher circulating 25-hydroxyvitamin D [25(OH)D] levels increase serum calcium levels and kidney stone disease (KSD) risk.

METHODS

Summary data for KSD were obtained from the UK biobank genome-wide association study (6536 cases and 388 508 controls). We acquired summary data for 25(OH)D from 120 618 Europeans and another large-scale analysis (443 734 Europeans) for primary and secondary analysis. Random-effect inverse-variance weighted (IVW) and 7 additional sensitivity analyses were applied. Next, multivariable Mendelian randomization (MVMR) was performed by introducing data for serum calcium levels.

RESULTS

Genetic predisposition for a 1-SD higher 25(OH)D level was associated with increased serum calcium levels (IVW; beta, 0.014; 95% CI, 0.010-0.018; P = 7.64E-10). Genetically predicted higher circulating 25(OH)D levels were associated with increased the risk of KSD, with per 1-SD odds ratios (ORs) of 1.47 (95% CI, 1.22-1.77; P = 5.49E-05) and 1.36 (95% CI, 1.03-1.80; P = 0.029) using the IVW and MVMR-Egger methods, respectively. In secondary analysis, similar results were found: 25(OH)D was associated with an increased risk of KSD in univariate Mendelian randomization (IVW; OR 1.71; 95% CI, 1.26-2.32; P = 0.001) and MVMR (OR 1.43; 95% CI, 1.16-1.76; P < 0.001) analyses. Most sensitivity analyses were consistent with the primary results, both for the primary and secondary analyses.

CONCLUSIONS

Our study supports that higher genetically predicted lifelong circulating 25(OH)D levels are associated with higher calcium levels and KSD risk. The effects of 25(OH)D on KSD were partially attenuated-but still significant-in MVMR.

Utilization of evidence-based guidelines for prevention of obesity and hypercholesterolemia among primary healthcare physicians in southwest of Saudi Arabia

To evaluate knowledge and use of evidence-based guidelines for prevention of obesity and hypercholesterolemia among primary healthcare physicians in Jazan, Saudi Arabia.This cross-sectional study targeted 170 primary healthcare centres (PHCs) in Jazan. Measurement of study's variables was completed during personal interviews. The content of the study instrument was based on The Saudi Guidelines on the Prevention and Management of Obesity and The Cholesterol Management Guide for Healthcare Practitioners.A total of 234 physicians participated in this study. The age of the physicians varied between 25 and 65 years and 51.7% of them were females. Knowledge of the physicians about the eat-well plate recommendations was very low, with none of the physicians reporting the recommended daily portions of fruits and vegetables. Less than 20% of the physicians knew the cutoff points for considering central obesity among male and female individuals. Only 21% of the physicians reported adherence concerning screening for obesity and 42% reported adherence to the guidelines concerning screening for hypercholesterolemia. Only 9% of the physicians were adherent to the guidelines concerning reducing the risk of obesity and only 13% reported adherence to the guidelines related to the reduction of hypercholesterolemia risk.The current investigation detected a low level of knowledge and adherence concerning the evidence-based practice related to prevention of the obesity and hypercholesterolemia and therefore limited role of PHC physicians in the prevention of obesity or hypercholesterolemia.

Guideline Adherence of β-blocker Initiating Dose and its Consequence in Hospitalized Patients With Heart Failure With Reduced Ejection Fraction

Background: We aim to investigate the guideline adherence of β-blocker (BB) initiating dose in Chinese hospitalized patients with heart failure with reduced ejection fraction (HFrEF) and whether the adherence affected the in-hospital outcomes. Methods: This was a retrospective study of patients hospitalized with HFrEF who had initiated BBs during their hospitalization. We defined adherence to clinical practice guidelines as initiating BB with standard dose and non-adherence to guidelines if otherwise, and examined the association between adherence to guidelines and in-hospital BB-related adverse events. Subgroup analyses based on sex, age, coronary heart disease, and hypertension were performed. Results: Among 1,104 patients with HFrEF initiating BBs during hospitalization (median length of hospitalization, 12 days), 304 (27.5%) patients received BB with non-adherent initiating dose. This non-adherence was related to a higher risk (hazard ratio [95% confidence interval]) of BB dose reduction or withdrawal (1.78 [1.42 to 2.22], P < 0.001), but not significantly associated with risks of profound bradycardia, hypotension, cardiogenic shock requiring intravenous inotropes, and severe bronchospasm requiring intravenous steroid during hospitalization. Conclusion: This study identified that over a fourth of patients had received BBs with an initiating dose that was not adherent to guidelines in Chinese hospitalized patients with HFrEF, and this non-adherence was associated with BB dose reduction or withdrawal during hospitalization.

Surgical clinical trials with non-inferiority design: a cross-sectional bibliometric analysis

Background

Wide-spread concerns have been raised about possible bias in published surgical non-inferiority trials. Therefore, we performed a comprehensive bibliometric analysis to identify the existence of bias, and provided recommendations for future non-inferiority trials.

Methods

Databases including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched (last update on 27 April 2020) to include published phase II and phase III non-inferiority surgical trials. We collected general information and parameters associated with trial design. The association between extracted factors and establishment of non-inferiority was then analyzed.

Results

A total of 347 trials were included in this study. Only 13 (3.7%) trials reported the pre-specified non-inferiority margin in registration, and 99 (28.5%) trials justified margin selection in ultimate trial publications. A significant association was found between industry funding and increased odds of achieving non-inferiority [odds ratio (OR): 1.17, 95% confidence interval (CI): 1.06 to 1.30, P=0.001]. Moreover, trials which had been presented in conferences were less likely to claim non-inferiority (OR: 0.83, 95% CI: 0.69 to 0.99, P=0.035).

Conclusions

Our study was the first quantitative analysis revealing the presence of biases in findings of existing surgical non-inferiority trials, which could possibly mislead surgeons’ clinical decision making. We suggest improving reporting of detailed study design especially funding sources as well as margin justification for future trials. We also encourage conference presentation of ongoing trials prior to the ultimate publication.

Non-inferiority in cancer clinical trials was associated with more lenient margins and higher hypothesized outcome event rates

OBJECTIVE

To identify potential bias in non-inferiority design of published cancer trials, and to provide suggestions for future practice.

STUDY DESIGN AND SETTING

We systematically searched MEDLINE, Embase and CENTRAL databases (until April 17, 2020) to obtain non-inferiority phase III cancer trials and protocols. Distribution of essential characteristics and study design parameters was compared between trials with and without concluding non-inferiority using multivariable logistic regression.

RESULTS

A total of 291 eligible trials were included. We observed that increased odds of concluding non-inferiority was significantly associated with more lenient non-inferiority margins (OR = 1•94, 95% CI 1•02-3•69) and higher hypothesized event rate (OR = 1•24, 95% CI 1•06-1•47). Trials that established non-inferiority adopted margins that were more dispersedly distributed (dispersion OR = 2•90, 95% CI 1•88-4.48).

CONCLUSION

Although limited by the exploratory nature, our study demonstrated existence of possible distorted non-inferiority design which could incur excess non-inferiority in cancer clinical trials. Pre-registration and transparent reporting of detailed non-inferiority design is imperative for future research.

Metformin in Patients With COVID-19: A Systematic Review and Meta-Analysis

Importance/Background: The coronavirus disease (COVID-19) pandemic is a critical public health issue. Evidence has shown that metformin favorably influences COVID-19 outcomes. This study aimed to assess the benefits and risks of metformin in COVID-19 patients. Methods: We searched the PubMed, Embase, Cochrane Library, and Chinese Biomedical Literature Database from inception to February 18, 2021. Observational studies assessing the association between metformin use and the outcomes of COVID-19 patients were included. The primary outcome was mortality, and the secondary outcomes included intubation, deterioration, and hospitalization. Random-effects weighted models were used to pool the specific effect sizes. Subgroup analyses were conducted by stratifying the meta-analysis by region, diabetic status, the adoption of multivariate model, age, risk of bias, and timing for adding metformin. Results: We identified 28 studies with 2,910,462 participants. Meta-analysis of 19 studies showed that metformin is associated with 34% lower COVID-19 mortality [odds ratio (OR), 0.66; 95% confidence interval (CI), 0.56-0.78; I 2 = 67.9%] and 27% lower hospitalization rate (pooled OR, 0.73; 95% CI, 0.53-1.00; I 2 = 16.8%). However, we did not identify any subgroup effects. The meta-analysis did not identify statistically significant association between metformin and intubation and deterioration of COVID-19 (OR, 0.94; 95% CI, 0.77-1.16; I 2 = 0.0% for intubation and OR, 2.04; 95% CI, 0.65-6.34; I 2 = 79.4% for deterioration of COVID-19), respectively. Conclusions: Metformin use among COVID-19 patients was associated with a reduced risk of mortality and hospitalization. Our findings suggest a relative benefit for metformin use in nursing home and hospitalized COVID-19 patients. However, randomized controlled trials are warranted to confirm the association between metformin use and COVID-19 outcomes. Study Registration: The study was registered on the PROSPERO on Feb 23, 2021 (CRD42021238722).

Sodium-Glucose Co-Transporter-2 Inhibitors in Non-Diabetic Adults With Overweight or Obesity: A Systematic Review and Meta-Analysis

Background

Sodium-glucose-cotransporter-2 (SGLT2) inhibitors have proven to be effective in improving glycemic control and lowering body weight in patients with type 2 diabetes mellitus. However, the efficacy and safety on weight loss in adults with overweight or obesity but not diabetes remain unclear. In this article, we aimed to identify the efficacy and safety of SGLT2 inhibitors in adults with overweight or obesity but not diabetes in randomized controlled studies (RCTs).

Methods

We searched for RCTs concerning SGLT2 inhibitors in adults with overweight or obesity but not diabetes in Medline (Ovid SP), Embase (Ovid SP), Cochrane Central Register of Controlled Trials (Ovid SP), and ClinicalTrials.gov up to February 2021. The primary outcomes were changes in body weight and body mass index (BMI). Trial sequential analysis (TSA) was used to test the reliability of the primary outcomes. We analyzed the data using Review Manager 5.3 and pooled data to calculate the mean differences (MDs) or the relative risk (RR). We assessed the evidence quality of evidence of outcomes according to GRADE.

Results

Six randomized controlled trials involving 872 individuals were included in the meta-analysis. Compared to the placebo group, the SGLT2 inhibitors group had statistically significant reductions in absolute changes in body weight (MD: -1.42 kg, 95% CI: -1.70 to -1.14; P<0.00001) and BMI (MD: -0.47 kg/m2, 95% CI: -0.63 to -0.31; P<0.00001) in SGLT2 inhibitors group, as indicated by TSA. However, no significant benefits were observed in the SGLT2 inhibitors group in terms of waist circumference (MD: -1.34 cm, 95%CI: -2.75 to 0.07; Z=1.86, P=0.06) compared with the placebo group. The GRADE profiles indicated very low-quality evidence for body weight change and low-quality evidence for BMI change. SGLT2 inhibitors were generally safe and well tolerated.

Conclusion

SGLT2 inhibitors could be used in selected adults with overweight and obesity but not diabetes if they are at low risk of genital infection and urinary infection. Further studies are warranted to confirm the efficacy and safety of SGLT2 inhibitors in adults with overweight or obesity but not diabetes for long-term weight management.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/#loginpage], identifier [PROSPERO, CRD42021252931].

Knowledge, Attitude, and Practice of Metformin Extended-Release Tablets Among Clinicians in China: A Cross-Sectional Survey

Background: Metformin extended-release (XR) is a once-daily alternative conventional immediate-release (IR) tablet for adults with type 2 diabetes.

Aim: This study aimed to investigate the knowledge, attitude, and practice of the use of metformin XR tablets among clinicians.

Methods: We conducted a cross-sectional online survey among endocrinologists, general practitioners, and internists, who are taking routine care of adults with type 2 diabetes in health institutes at all levels in Sichuan Province, China. We designed an online questionnaire including the demographic information, knowledge, attitude, and practice about metformin XR tablets.

Results: We included 158 clinicians, 67.7% of whom were females and 63.9% were from tertiary hospitals. The median age was 39.6 years (ranging between 22 and 62 years). Only 8.2% of the clinicians correctly answered the knowledge questions, 82.3% and 62.0% of the responders assumed that metformin XR had superior efficacy and tolerability to the metformin IR, respectively. Only 46.8% of the clinicians prescribed the metformin XR based on the patient’s preference for once daily frequency.

Conclusion: The knowledge, attitude, and practice of metformin XR among Chinese clinicians need improving. Clinicians need credible information to support their clinical decision-making regarding metformin XR.

Cardiovascular Safety of Febuxostat and Allopurinol in Hyperuricemic Patients With or Without Gout: A Network Meta-Analysis

Background: Hyperuricemia is a common metabolic disease and has become a public health problem because of its increasing prevalence and association with comorbidities. Allopurinol and febuxostat are recommended as the first-line treatments for hyperuricemia and gout. But cardiovascular safety between febuxostat and allopurinol is still controversial. The purpose of this study is to compare the cardiovascular safety of XOIs and placebo in hyperuricemic patients with or without gout. Methods: PubMed, Embase via OVID, Cochrane Library, CNKI, Wanfang, and VIP were searched from their earliest records to February 8th 2021. ClinicalTrials.gov was also searched for unpublished data. The reference lists of included studies and relevant review articles investigating the cardiovascular safety of XOIs in hyperuricemia patients are screened for potentially eligible studies. Randomized controlled trials (RCTs) evaluating allopurinol (100~900 mg/d), febuxostat (20~120 mg/d), or placebo for hyperuricemia were included. The outcomes were incidence of MACE, non-fatal MI, non-fatal stroke, and cardiovascular death. We conducted a Bayesian random-effects network meta-analysis on the included randomized controlled trials using the Markov Chain Monte Carlo simulation method. The grading of recommendations assessment, development, and evaluation (GRADE) approach was used to assesses the certainty of the evidence. Results: Ten RCTs with 18,004 participants were included. The network estimates showed that there was no significant difference observed among febuxostat, allopurinol, and placebo regarding outcomes. The certainty of the evidence ranged from very low to moderate. The probabilities of rankings and SUCRA showed that compared to placebo, febuxostat, and allopurinol might prevent adverse cardiovascular events. Conclusion: Febuxostat is not associated with increasing risk of adverse cardiovascular events compared to allopurinol; and compared to placebo, whether febuxostat and allopurinol reduce the risk of adverse cardiovascular events remains uncertain.

Long-Acting Metformin Vs. Metformin Immediate Release in Patients With Type 2 Diabetes: A Systematic Review

Background: Metformin, a commonly used antidiabetic medication, is available in both an immediate-release (IR) formulation and a long-acting formulation (metformin extended-release; XR). Objective: We performed a systematic review to compare the effectiveness, safety, and patient compliance and satisfaction between the metformin IR and XR formulations. Method: We searched for randomized control trials (RCTs) and observational studies comparing the effectiveness, safety, or patient compliance and satisfaction of metformin XR with metformin IR using the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases. Following report screening, data collection, and risk of bias assessment, we separately pooled data from RCTs and observational studies using the Grading of Recommendation Assessment, Development, and Evaluation approach to rate the quality of evidence. Result: We included five RCTs, comprising a total of 1,662 patients, and one observational study, comprising 10,909 patients. In the meta-analyses, no differences were identified in outcomes of effectiveness and safety between the two forms of metformin (including change in HbA1c: mean difference (MD), 0.04%, 95% confidence interval [CI], -0.05-0.13%, fasting blood glucose: MD, -0.03 mmol/L, 95% CI, -0.22-0.15 mmol/L, postprandial blood glucose: MD, 0.50 mmol/L, 95% CI, -0.71-1.72 mmol/L, adverse events of abdominal pain: relative risk (RR), 1.15, 95% CI, 0.57-2.33, all-cause death (RR, 3.02, 95% CI 0.12-73.85), any adverse events (RR, 1.14, 95% CI 0.97-1.34), any adverse events leading to treatment discontinuation: RR, 1.51, 95% CI, 0.82-2.8, any gastrointestinal adverse events: RR, 1.09, 95% CI, 0.93-1.29, diarrhea: RR, 0.82, 95% CI, 0.53-1.27, flatulence: RR, 0.43, 95% CI, 0.15-1.23, nausea: RR, 0.97, 95% CI, 0.64-1.47, severe adverse events: RR, 0.64, 95% CI, 0.28-1.42, and vomiting: RR, 1.46, 95% CI, 0.6-3.56). Data from both the RCTs and the observational study indicate mildly superior patient compliance with metformin XR use compared with metformin IR use; this result was attributable to the preference for once-daily administration with metformin XR. Conclusion: Our systematic review indicates that metformin XR and IR formulations have similar effectiveness and safety, but that metformin XR is associated with improved compliance to treatment.

SGLT-2 inhibitors or GLP-1 receptor agonists for adults with type 2 diabetes: a clinical practice guideline

CLINICAL QUESTION

What are the benefits and harms of sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists when added to usual care (lifestyle interventions and/or other diabetes drugs) in adults with type 2 diabetes at different risk for cardiovascular and kidney outcomes?

CURRENT PRACTICE

Clinical decisions about treatment of type 2 diabetes have been led by glycaemic control for decades. SGLT-2 inhibitors and GLP-1 receptor agonists are traditionally used in people with elevated glucose level after metformin treatment. This has changed through trials demonstrating atherosclerotic cardiovascular disease (CVD) and chronic kidney disease (CKD) benefits independent of medications' glucose-lowering potential.

RECOMMENDATIONS

The guideline panel issued risk-stratified recommendations concerning the use of SGLT-2 inhibitors or GLP-1 receptor agonists in adults with type 2 diabetes• Three or fewer cardiovascular risk factors without established CVD or CKD: Weak recommendation against starting SGLT-2 inhibitors or GLP-1 receptor agonists.• More than three cardiovascular risk factors without established CVD or CKD: Weak recommendation for starting SGLT-2 inhibitors and weak against starting GLP-1 receptor agonists.• Established CVD or CKD: Weak recommendation for starting SGLT-2 inhibitors and GLP-1 receptor agonists.• Established CVD and CKD: Strong recommendation for starting SGLT-2 inhibitors and weak recommendation for starting GLP-1 receptor agonists.• For those committed to further reducing their risk for CVD and CKD outcomes: Weak recommendation for starting SGLT-2 inhibitors rather than GLP-1 receptor agonists.

HOW THIS GUIDELINE WAS CREATED

An international panel including patients, clinicians, and methodologists created these recommendations following standards for trustworthy guidelines and using the GRADE approach. The panel applied an individual patient perspective.

THE EVIDENCE

A linked systematic review and network meta-analysis (764 randomised trials included 421 346 participants) of benefits and harms found that SGLT-2 inhibitors and GLP-1 receptor agonists generally reduce overall death, and incidence of myocardial infarctions, and end-stage kidney disease or kidney failure (moderate to high certainty evidence). These medications exert different effects on stroke, hospitalisations for heart failure, and key adverse events in different subgroups. Absolute effects of benefit varied widely based on patients' individual risk (for example, from five fewer deaths in the lowest risk to 48 fewer deaths in the highest risk, for 1000 patients treated over five years). A prognosis review identified 14 eligible risk prediction models, one of which (RECODe) informed most baseline risk estimates in evidence summaries to underpin the risk-stratified recommendations. Concerning patients' values and preferences, the recommendations were supported by evidence from a systematic review of published literature, a patient focus group study, a practical issues summary, and a guideline panel survey.

UNDERSTANDING THE RECOMMENDATION

We stratified the recommendations by the levels of risk for CVD and CKD and systematically considered the balance of benefits, harms, other considerations, and practical issues for each risk group. The strong recommendation for SGLT-2 inhibitors in patients with CVD and CKD reflects what the panel considered to be a clear benefit. For all other adults with type 2 diabetes, the weak recommendations reflect what the panel considered to be a finer balance between benefits, harms, and burdens of treatment options. Clinicians using the guideline can identify their patient's individual risk for cardiovascular and kidney outcomes using credible risk calculators such as RECODe. Interactive evidence summaries and decision aids may support well informed treatment choices, including shared decision making.

Deficiencies in Planning Interventional Trial Registration of COVID-19 in China

Background: The coronavirus disease 2019 (COVID-19) pandemic has affected the world since late 2019. The efforts to control the spread of the virus need to be supported by credible evidence. Therefore, we analyzed the rationality of the timeline and geographic distribution of COVID-19 trial registration in mainland China. Methods: We searched the Chinese Clinical Trial Registry (ChiCTR, http://www.chictr.org.cn/) and International Clinical Trials Registry Platform (ICTRP, https://www.who.int/ictrp/en/) using keywords including novel coronavirus, coronavirus pneumonia, 2019-nCoV, COVID-19, and SARS-COV-2 from 1 December 2019 to 27 April 2020 and included interventional randomized and non-randomized trials including patients with confirmed cases of COVID-19 in mainland China. The registered trials were reviewed, and data were independently extracted by two reviewers based on the inclusion criteria. Results: A total of 263 registered interventional trials were included in the study. We defined the sample size index (SI) as the total number of patients needed by the trials divided by the total number of patients diagnosed with COVID-19. A total of 84,341 patients had been diagnosed with COVID-19 in China as of 26 April 2020, and the included trials had a combined sample size of 31,156 patients (SI: 0.37). After control of the COVID-19 epidemic was achieved in China (February 18, 2020), the SI was 1.54, suggesting that the number of patients needed by the trials was greater than the number of newly diagnosed patients. The SIs in 8 out of 26 provinces in mainland China were >1. Conclusions: Our results suggested a clear over registration of COVID-19 trials in China, especially after control of the pandemic was achieved, preventing the generation of high-quality evidence.

Different Lipid Parameters in Predicting Clinical Outcomes in Chinese Statin-Naïve Patients After Coronary Stent Implantation

Background: Low-density lipoprotein cholesterol (LDL-C) is a critical surrogate outcome for cardiovascular disease (CVD). Recent observational studies identified different predictive lipid parameters, but these have not been fully validated in the Chinese population. This study aimed to compare the predictive value of lipid parameters for cardiovascular outcomes in Chinese statin-naïve patients who underwent percutaneous coronary intervention (PCI).

Methods: We retrospectively recruited statin-naïve patients who underwent PCI for stable angina and acute coronary syndrome at Sichuan Provincial People's Hospital between 1 January 2016 and 31 December 2017. A follow-up was conducted via outpatient visits or telephone. We divided patients into three groups based on lipid parameter tertiles. We calculated the hazard ratios (HRs) of the highest and lowest tertiles for major adverse cardiovascular events (MACEs) using multivariate Cox proportional hazards regression. We compared the association strength of lipid parameters with MACEs using the HR of non-LDL-C lipid parameters relative to LDL-C.

Results: Among 445 included patients, the highest LDL-C, LDL-C/high-density lipoprotein cholesterol (HDL-C), atherosclerosis index, and non-HDL-C level tertiles were associated with an average increase of 165% (HR 2.65, confidence interval [CI] 1.26 to 5.61; P = 0.01), 324% (HR 4.24, CI 1.89 to 9.52; P < 0.001), 152% (HR 2.52, CI 1.22 to 5.22; P = 0.01), and 125% (HR 2.25, CI 1.09 to 4.64; P = 0.01) in the hazard of composite CVD, respectively. Lipoprotein (a) levels did not show a significant association with the endpoints. Except for LDL-C/HDL-C, different lipid parameter HR ratios were <1.0; none were statistically significant.

Conclusion: Compared with non-LDL-C lipid parameters, LDL-C acts better predictive value for cardiovascular outcomes in general Chinese statin-naïve post-PCI patients.

Diabetes in Patients With Heart Failure With Reduced Ejection Fraction During Hospitalization: A Retrospective Observational Study

BACKGROUND

Diabetes is prevalent worldwide including hospitalized patients with heart failure with reduced ejection fraction (HFrEF). This retrospective study investigated the association of diabetes with in-hospital adverse events in patients with HFrEF.

METHODS

We analyzed data from electronic medical records of patients hospitalized with HFrEF in West China Hospital of Sichuan University from January 1, 2011, to September 30, 2018. Propensity score matching balances the baseline characteristics between patients with and without diabetes. Logistic and Poisson regressions investigated the association of diabetes with risks of intubation, cardiogenic shock, acute kidney injury (AKI), intensive care unit (ICU) admission and death during hospitalization, and length of ICU and hospital stay in the matched cases.

RESULTS

Among 6,022 eligible patients (including 1,998 with diabetes), 1,930 patient pairs with and without diabetes were included by propensity score matching. Patients with diabetes had a significantly increased risk of intubation (odds ratio [OR], 2.69; 95% confidence interval [CI], 2.25-3.22; P<0.001), cardiogenic shock (OR, 2.01; 95% CI, 1.72-2.35; P<0.001), AKI at any stage (OR, 1.67; 95% CI, 1.44-1.94; P<0.001), ICU admission (OR, 1.89; 95% CI, 1.65-2.15; P<0.001), and death (OR, 4.25; 95% CI, 3.06-6.02; P<0.001) during hospitalization. Patients with diabetes had longer ICU (median difference, 1.47 days; 95% CI, 0.96-2.08; P<0.001) and hospital stay (2.20 days; 95% CI, 1.43-2.86; P<0.001) than those without diabetes. There were potential subgroup effects by age and by hypertension, and CKD status on the association of diabetes with risk of AKI at any stage; and subgroup effects by sex and CKD status on the association of diabetes with risk of intubation. The increase in length of hospital stay was larger in patients without hypertension than those with hypertension.

CONCLUSIONS

Among patients with HFrEF, those with diabetes have a worse prognosis, including a higher risk of in-hospital intubation, cardiogenic shock, AKI, ICU admission and death during hospitalization, and longer ICU and hospital stay.