Complications of diabetes: screening for retinopathy and management of foot ulcers

Association between antidepressants and the risk of diabetic foot ulcers and amputation in antidepressant-naïve type 2 diabetes mellitus patients: A nested case-control study

AIMS

Antidepressants are widely used by individuals with type 2 diabetes mellitus (T2DM). This study aimed to explore the correlation between antidepressant use, considering specific antidepressant subclasses or cumulative doses, and diabetic foot ulcer (DFU) risk.

METHODS

This nested case-control study was conducted using a representative population-based Korean cohort database from 2002 to 2019. Participants with DFUs were matched with participants without DFUs based on age, sex, date of T2DM diagnosis, and follow-up duration. In total, 791 DFUs and 3900 controls were included. The association between antidepressant use or cumulative dose of each antidepressant subclass, DFU risk and amputation risk was examined using a conditional logistic regression model.

RESULTS

Antidepressant ever-use was associated with an increased incidence of DFUs compared with non-use. Furthermore, an increase in DFU risk was evident with increasing cumulative antidepressant dosage, particularly among tricyclic antidepressant (TCA) ever-users and selective serotonin reuptake inhibitors (SSRIs) ever-users. Additionally, antidepressant ever-users displayed a higher risk of DFUs requiring amputation, which was consistently observed when the cumulative dosages of overall antidepressants and TCAs were considered.

CONCLUSION

Caution is advised when administering TCAs and SSRIs in antidepressant-naïve T2DM patients to reduce DFU and the consequent amputation risk.

An Effective Method for Detecting and Classifying Diabetic Retinopathy Lesions Based on Deep Learning

Diabetic retinopathy occurs as a result of the harmful effects of diabetes on the eyes. Diabetic retinopathy is also a disease that should be diagnosed early. If not treated early, vision loss may occur. It is estimated that one third of more than half a million diabetic patients will have diabetic retinopathy by the 22nd century. Many effective methods have been proposed for disease detection with deep learning. In this study, unlike other studies, a deep learning-based method has been proposed in which diabetic retinopathy lesions are detected automatically and independently of datasets, and the detected lesions are classified. In the first stage of the proposed method, a data pool is created by collecting diabetic retinopathy data from different datasets. With Faster RCNN, lesions are detected, and the region of interests are marked. The images obtained in the second stage are classified using the transfer learning and attention mechanism. The method tested in Kaggle and MESSIDOR datasets reached 99.1% and 100% ACC and 99.9% and 100% AUC, respectively. When the obtained results are compared with other results in the literature, it is seen that more successful results are obtained.

A micro costing analysis of the development of a primary care intervention to improve the uptake of diabetic retinopathy screening

Background

The application of economic analysis within implementation science is still developing and the cost of intervention development, which differs markedly from the costs of initial implementation and maintenance, is often overlooked. Our aim was to retrospectively cost the development of a multifaceted intervention in primary care to improve attendance at diabetic retinopathy screening.

Methods

A retrospective micro costing of developing the intervention from the research funder perspective was conducted. It was based on a systematic intervention development process involving analysis of existing audit data and interviews with patients and healthcare professionals (HCPs), conducting consensus meetings with patients and HCPs, and using these data together with a rapid review of the effectiveness of interventions, to inform the final intervention. Both direct (non-personnel, e.g. travel, stationary, room hire) and indirect (personnel) costs were included. Data sources included researcher time logs, payroll data, salary scales, an online financial management system, invoices and purchase orders. Personnel involved in the intervention development were consulted to determine the activities they conducted and the duration of their involvement. Sensitivity and scenario analyses were conducted to estimate uncertainty around parameters and scope.

Results

The total cost of intervention development (July 2014–January 2019) was €40,485 of which 78% were indirect (personnel) costs (€31,451). In total, personnel contributed 1368 h to intervention development. Highest cost activities were the patient interviews, and consensus process, contributing 23% and 34% of the total cost. Varying estimated time spent on intervention development activities by + 10% increased total intervention development cost by 6% to €42,982.

Conclusions

Our results highlight that intervention development requires a significant amount of human capital input, combining research experience, patient and public experience, and expert knowledge in relevant fields. The time committed to intervention development is critical but has a significant opportunity cost. With limited resources for research on developing and implementing interventions, capturing intervention development costs and incorporating them as part of assessment of cost-effective interventions, could inform research priority and resource allocation decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01085-4.

Relationship of visual impairment and peripheral artery disease with the occurrence of diabetic foot ulcers in Dr. Moewardi Hospital

Objective

One of the diabetes mellitus (DM) complications is foot ulcers. Foot ulcers are influenced by many factors. DM puts patients at risk of injury because of visual impairment. Hyperglycemia can damage blood vessels, which results in peripheral artery disease (PAD). The purpose of this study was to find the relationship of visual impairment and PAD with diabetic foot ulcers.

Methods

This research used observational analytic study with case–control methods. It used purposive sampling in 34 DM patients with foot ulcers and 34 DM patients without foot ulcers. The research instruments were an interview guide to assess visual impairment, physical examination to assess PAD, and documentation study, which was used to know the incidence of diabetic ulcers.

Results

The results showed that the respondents who experienced ulcers with visual impairment were 44.1% and the respondents who had foot ulcers with PAD were 73.5%. The results of statistical tests showed that there was no relationship between visual impairment and the incidence of ulcers (P = 0.166). The respondents with PAD will have a chance to suffer from foot ulcers 5.808 times higher than those who do not have PAD.

Conclusions

There is no relationship between visual impairment and the incidence of diabetic foot ulcers in Dr. Moewardi Hospital, but there is relationship between PAD and the incidence of diabetic foot ulcers in Dr. Moewardi Hospital. Suggestions of this study are to do foot screening and educate about the importance of foot care to prevent the occurrence of diabetic ulcers.

Diabetic retinopathy techniques in retinal images: A review

The diabetic retinopathy is the main reason of vision loss in people. Medical experts recognize some clinical, geometrical and haemodynamic features of diabetic retinopathy. These features include the blood vessel area, exudates, microaneurysm, hemorrhages and neovascularization, etc. In Computer Aided Diagnosis (CAD) systems, these features are detected in fundus images using computer vision techniques. In this paper, we review the methods of low, middle and high level vision for automatic detection and classification of diabetic retinopathy.We give a detailed review of 79 algorithms for detecting different features of diabetic retinopathy during the last eight years.

Cost-utility of exenatide once weekly compared with insulin glargine in patients with type 2 diabetes in the UK

OBJECTIVE

To compare the cost-utility of exenatide once weekly (EQW) and insulin glargine in patients with type 2 diabetes in the United Kingdom (UK).

RESEARCH DESIGN AND METHODS

The IMS CORE Diabetes Model was used to project clinical and economic outcomes for patients with type 2 diabetes treated with EQW or insulin glargine. Treatment effects and patient baseline characteristics (mean age: 58 years, mean glycohaemoglobin: 8.3%) were taken from the DURATION-3 study. Unit costs and health state utility values were derived from published sources. As the price of EQW is not yet known, the prices of two currently available glucagon-like peptide-1 products were used as benchmarks. To reflect diabetes progression, patients started on EQW switched to insulin glargine after 5 years. The analysis was conducted from the perspective of the UK National Health Service over a time horizon of 50 years with costs and outcomes discounted at 3.5%. Sensitivity analyses explored the impact of changes in input data and assumptions and investigated the cost utility of EQW in specific body mass index (BMI) subgroups.

MAIN OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER) for EQW compared with insulin glargine.

RESULTS

At a price equivalent to liraglutide 1.2 mg, EQW was more effective and more costly than insulin glargine, with a base case ICER of £10,597 per quality-adjusted life-year (QALY) gained. EQW was associated with an increased time to development of any diabetes-related complication of 0.21 years, compared with insulin glargine. Three BMI subgroups investigated (<30, 30-35 and >35 kg/m(2)) reported ICERs for EQW compared with insulin glargine ranging from £9425 to £12,956 per QALY gained.

CONCLUSIONS

At the prices investigated, the cost per QALY gained for EQW when compared with insulin glargine in type 2 diabetes in the UK setting, was within the range normally considered cost effective by NICE. Cost effectiveness in practice will depend on the final price of EQW and the extent to which benefits observed in short-term randomised trials are replicated in long-term use.

Diagnosis and management of diabetic neuropathy

Diabetic sensorimotor polyneuropathy (DSP) remains the most common microvascular complication of both type I and type 2 diabetes, and poses a unique set of management challenges in the prevention of foot complications. Although different quantitative tests are available, the preliminary diagnosis of DSP can be reliably made using simple and rapid screening tests in the family physician's office or in the diabetes clinic. The Semmes-Weinstein 10-g monofilament examination is a popular, simple clinical modality for the prediction of early DSP, foot ulceration, and amputation, and, in turn, a predictor of mortality in patients with diabetes. The management of DSP is centered on optimal glycemic control, diligent foot care, and pain control as a means of preventing the progression of DSP and reducing the morbidity associated with foot complications.

Multifaceted support to improve clinical decision making in diabetes care: a randomized controlled trial in general practice

AIMS

To evaluate the effectiveness of a multifaceted intervention to improve the clinical decision making of general practitioners (GPs) for patients with diabetes. To identify practice characteristics which predict success.

METHODS

Cluster randomized controlled trial with 124 practices and 185 GPs in The Netherlands. The intervention group received feedback reports and support from a facilitator; the control group received no special attention. Outcome measures were the compliance rates with evidence-based recommendations pertaining to discussion of body weight control, discussion of problems with medication, blood pressure measurement, foot examination, eye examination, initiating anti-diabetic medication or increasing the dosage in cases of uncontrolled blood glucose, and scheduling a follow-up appointment.

RESULTS

The GPs reported on their clinical decision making in 1410 consultations with Type 2 diabetic patients at baseline and 1449 consultations after the intervention period. The intervention resulted in statistically significant improvement for two of the seven outcome measures: foot examination (odds ratio 1.68; 95% confidence interval 1.19-2.39) and eye examination (1.52; 1.07-2.16). Discussion of problems with medication showed a near significant trend towards increased benefit for the intervention group (1.52; 0.99-2.32). Practice characteristics were not found to be related to the success of the intervention.

CONCLUSIONS

Feedback reports with support from facilitators appear to increase rates of foot examination and eye examination in general practice. Alternative interventions should be explored to improve the pursuit of metabolic control by GPs.