Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2020

Dietary polyunsaturated fatty acids intake is negatively associated with hyperuricemia: The National Health and Nutrition Examination Survey 2003-2015

BACKGROUND AND AIMS

The objective of this research was to explore the associations between dietary PUFAs intake and hyperuricemia risk.

METHODS AND RESULTS

Based on the National Health and Nutrition Examination Survey (NHANES) 2003-2015, all eligible individuals were divided into hyperuricemia and non-hyperuricemia groups based on diagnostic criteria for hyperuricemia (serum uric acid >420 μmol/L for men and >360 μmol/L for women). Multivariate-adjusted logistic regression was employed to explore the relationship between dietary PUFAs intake and hyperuricemia risk. Total PUFAs and their subtypes were modeled to isocalorically replace saturated fatty acids (SFAs) and monounsaturated fatty acids (MUFAs). Higher intake of n-3 PUFAs, n-6 PUFAs, linoleic acid (LA), alpha-linoleic acid (ALA), and non-marine PUFAs intake correlated with decreased hyperuricemia risk, with adjusted odds ratio (OR) and 95% confidence interval (95%CIs) were 0.77 (0.63, 0.93), 0.75 (0.61, 0.92), 0.75 (0.61, 0.91), 0.69 (0.55, 0.87), and 0.73 (0.59, 0.91), respectively. Replacing 5% of total energy intake from SFAs with isocaloric PUFAs was associated with decreased odds of hyperuricemia in men (0.69 (0.57, 0.84)) and in individuals (0.81 (0.71, 0.92)). Similar trends were observed in the substitution of SFAs with non-marine PUFAs in men (0.87 (0.80, 0.94)) and in all individuals (0.92 (0.88, 0.98)). Sensitivity analyses exhibited consistent results with primary analyses.

CONCLUSION

Higher dietary intake of n-3 PUFAs, n-6 PUFAs, LA, ALA, and non-marine PUFAs was associated with decreased hyperuricemia risk. These results support the recommendation to substitute SFAs with PUFAs in diet.

Barriers and facilitators of self-management of diabetes amongst people experiencing socioeconomic deprivation: A systematic review and qualitative synthesis

BACKGROUND

The number of people living with diabetes is rising worldwide and a higher prevalence of diabetes has been linked to those experiencing socioeconomic deprivation. Self-management strategies are vital and known to reduce the risks of long-term complications amongst people living with diabetes. Lack of knowledge about self-care activity required to manage diabetes is a key barrier to successful self-management. Self-management interventions can be less effective in socioeconomically deprived populations which can increase the risk of exacerbating health inequalities. The purpose of this review is to identify and synthesise qualitative evidence on the barriers and facilitators of self-management of diabetes amongst people who are socioeconomically disadvantaged.

METHODS

MEDLINE, EMBASE, AMED, PsycINFO and CINAHL Plus were searched for qualitative studies concerning self-management of multiple long-term conditions amongst socioeconomically disadvantaged populations. Relevant papers which focused on diabetes were identified. Data were coded and thematically synthesised using NVivo.

FINDINGS

From the search results, 79 qualitative studies were identified after full-text screening and 26 studies were included in the final thematic analysis. Two overarching analytical themes were identified alongside a set of subthemes: (1) Socioeconomic barriers to diabetes self-management; healthcare costs, financial costs of healthy eating, cultural influences, living in areas of deprivation, competing priorities and time constraints, health literacy, (2) facilitators of diabetes self-management; lifestyle and having goals, support from healthcare providers, informal support.

DISCUSSION

Self-management of diabetes is challenging for people experiencing socioeconomic deprivation due to barriers associated with living in areas of deprivation and financial barriers surrounding healthcare, medication and healthy food. Support from healthcare providers can facilitate self-management, and it is important that people with diabetes have access to interventions that are designed to be inclusive from a cultural perspective as well as affordable.

PATIENT OR PUBLIC CONTRIBUTION

A patient advisory group contributed to the research questions and interpretation of the qualitative findings by reflecting on the themes developed.

Nomogram for Predicting Hypoglycemia in Type 2 Diabetes Mellitus Patients Treated with Insulin Pump During Enteral Nutrition

Purpose

To develop a prediction model for hypoglycemia in type 2 diabetes mellitus (T2DM) patients treated with an insulin pump during enteral nutrition.

Methods

This retrospective study included T2DM patients treated with an insulin pump during enteral nutrition at the First Affiliated Hospital of Jinan University, Guangzhou Red Cross Hospital, Foshan First People's Hospital, and Guangdong Provincial Hospital of Traditional Chinese Medicine between January 2016 and December 2023. The patients were randomized 3:1 to the training and validation sets. The risk factors for hypoglycemia were analyzed. A prediction model was developed.

Results

This study included 122 patients, and 57 patients had at least one hypoglycemic event during their hospitalization (46.72%). The multivariable logistic regression analysis showed that the time to reach the glycemic targets (odds ratio (OR)=1.408, 95% confidence interval (CI)=1.084-1.825, P=0.006), average glycemia (OR=0.387, 95% CI=0.233-0.643, P=0.010), coronary heart disease (OR=0.089, 95% CI=0.016-0.497, P<0.001), and the administration of hormone therapy (OR=6.807, 95% CI=1.128-41.081, P=0.037) were independently associated with hypoglycemia. A nomogram was built. The receiver operating characteristics analysis showed that the area under the curve of the model was 0.872 (95% CI=0.0.803-0.940) for the training set and 0.839 (95% CI=0.688-0.991) in the validation set.

Conclusion

A nomogram was successfully built to predict hypoglycemia in T2DM patients treated with an insulin pump during enteral nutrition, based on the time to reach the glycemic targets, average glycemia, coronary heart disease, and the administration of hormone therapy.

The Relationship between All-Cause Dementia and Acute Diabetes Complications among American Indian and Alaska Native Peoples

BACKGROUND

American Indian and Alaska Native people (AI/AN) bear a disproportionate burden of diabetes. Growing evidence shows significant associations between several acute diabetes complications and dementia among diabetes patients. However, little is known about these relationships among AI/AN adults. Here, we aim to investigate these associations among AI/AN adults.

METHODS

This cross-sectional study extracted data from the Indian Health Service's (IHS) National Data Warehouse and related administrative databases. A total of 29,337 IHS actual users with diabetes who were 45+ years old during fiscal year 2013 were included. All-cause dementia and diabetes complications were identified using ICD-9 diagnostic codes. Negative binomial regression models were used to evaluate the associations of interest.

RESULTS

Nearly 3% of AI/AN diabetes patients had a dementia diagnosis. After controlling for covariates, dementia was associated with a 94% higher rate of severe hypoglycemia (Incidence Rate Ratio [IRR = 1.94, 95% CI:1.50-2.51), 52% higher rate of severe hyperglycemia (IRR = 1.52, 95% CI, 1.11-2.08), and 92% higher rate of any acute complication (IRR = 1.92, 95% CI:1.53-2.41).

CONCLUSIONS

AI/AN diabetes patients with dementia suffered from considerably higher rates of acute diabetes complications than their counterparts without dementia. The clinical management of patients with comorbid diabetes and dementia is particularly challenging and may require individualized treatment approaches.

Physical and Mental Health Characteristics of Hospitalized COVID-19 Patients with and without Type 2 Diabetes Mellitus in Turkey

The aim of this study was to assess the rates of depression, anxiety, and stress and quality of sleeping among COVID-19 patients with and without type 2 diabetes mellitus (T2DM). A case and control design has been employed, involving patients affected by COVID-19 infection (884 with T2DM vs. 884 controls without T2DM) and hospitalized in Istanbul (Turkey) from January to December 2021. A multivariate stepwise regression approach was used to test the associations between sociodemographic, metabolic, serum markers, mental health scores, and T2DM/COVID-19 patients' clinical presentation. A statistically significant difference between T2DM and non-T2DM was found with respect to age, gender, BMI (body mass index), smoking, physical exercise, and physical comorbidities as well as levels of depression, anxiety, stress, and sleeping disorders (0.0003 ≤ all p = 0.025). With regard to serum biomarkers, vitamin D and ferritin were identified as useful parameters of reduction of glycated hemoglobin as well as COVID-19 infection among T2DM patients. This study detected that 25% of patients with COVID-19 and T2DM experienced mental distress, with sleeping disturbances and lifestyle changes markedly impacting their clinical outcome alongside metabolic and serum parameters.

Diabetes in Orthopaedic Sports Medicine Surgeries Standard Review

Diabetes mellitus has been shown to affect the outcomes of various orthopaedic procedures. Although orthopaedic sports medicine procedures tend to be less invasive and are often performed on younger and healthier patients, diabetes is associated with an increased risk of postoperative infection, readmission, and lower functional outcome scores. However, this risk may be moderated by the glycemic control of the individual patient, and patients with a low perioperative hemoglobin A1c may not confer additional risk. Further research is needed to evaluate the impact of diabetes on surgical outcomes in sports orthopaedics is needed, with the goal of evaluating mediating factors such as glycemic control in mind.

Glycemic Control in Patients with Type 1 Diabetes: Comparison of Holidaysversus Schooldays

BACKGROUND AND AIMS

To examine the influence of school life in children and adolescents with type 1 diabetes (T1D) by comparing the glycemic control and Ambulatory Glucose Profile (AGP) between the holidays and schooldays.

METHODS

This is a retrospective study conducted on 147 patients with T1D (14-19 years) who used an intermittently scanned Continuous Glucose Monitoring (isCGM) system to self-test their glucose levels during the periods of school time and holiday time. A record was maintained of the Continuous Glucose Monitoring (CGM) metrics i.e., Glucose Variability (GV) (%), mean Time in Range (TIR), Time above Range (TAR), Time below Range (TBR), and average time period of the hypoglycemic events during schooldays and the holidays.

RESULTS

The study revealed differences between the recorded values during the holidays and schooldays, in % in target 70-180 mg/dL (38.2 vs. 49.5; p = 0.039), mean glucose (194 vs. 185; p = 0.048), frequency of low glucose events (9.2 vs. 5.1; p = 0.036), mean duration of low glucose levels (117 vs. 65; p = 0.021), % TBR below 70 mg/dL (2.9 vs. 1.45; p = 0.023), % TBR below 54 mg/dL (1.1 vs. 0.51; p = 0.031), TAR 181-250 mg/dL (21.1 vs. 16.5; p = 0.037) and TAR >250 mg/dL (8.9 vs. 6.5; p = 0.043). On comparing the HbA1c levels of the study population recorded during the holidays (8.34%) with those recorded during the schooldays (8.13%), the HbA1c values during the school days were observed to be lower; however, no significant changes were noted in the HbA1c level between the holidays and schooldays. Concerning the FreeStyle Libre (FSL) scanning, the frequency during the holidays (n = 6.2) was significantly lower than during the schooldays (n = 9.5) (p = 0.042).

CONCLUSION

From the findings, it appears that children with T1D have good diabetes control during schooldays rather than during the holidays. To improve their glucose control during the holidays, these patients may also benefit from receiving greater attention and guidance.

Prevalence and risk factors associated with undiagnosed diabetes in India: Insights from NFHS-5 national survey

Background

Undiagnosed diabetes is a significant public health concern in India, considering the accumulative burden of diabetes and its long-term complications. We have estimated the prevalence and factors associated with undiagnosed diabetes in India.

Methods

We used data from the fifth round of the National Family Health Survey (NFHS-5, 2019-21) to estimate undiagnosed diabetes prevalence aged under 50 (15-49) years. A log-binomial model with survey-adjusted Poisson regression was used to estimate the prevalence risk ratio (PR) between undiagnosed diabetes and various factors. Multinomial logistic regression analysis was performed to examine the factors associated with diagnosed diabetes (vs. healthy) and undiagnosed diabetes (vs. healthy). All the analyses were survey-weighted and stratified by gender and reported with 95% confidence intervals.

Results

The prevalence of diabetes for individuals aged 15-49 years was found to be 4.90% (4.80 to 5.00%) from the NFHS-5. Among them, the proportion of individuals with undiagnosed diabetes was 24.82% (24.07 to 25.59%), with higher among males (28.82% (26.45 to 31.30%)) than females (24.22% (23.44 to 25.01%)). The overall prevalence of undiagnosed diabetes was 1.22% (1.18 to 1.26%), with a higher prevalence among males (1.60% (1.46 to 1.76%)) than females (1.17% (1.13 to 1.21%)). Individuals who are middle-aged (45-49), have a higher body mass index (BMI), and are in a lower wealth index group, or live in the southern regions of India are at a higher risk of being undiagnosed for diabetes.

Conclusion

One in every four having diabetes is undiagnosed. The study highlights the need for public health interventions to improve diabetes screening and access to health care, particularly among middle-aged individuals, and those with higher BMI, as well as addressing lifestyle and dietary factors. The findings also reveal disparities in diabetes burden among population subgroups in India, underscoring the need for targeted efforts.

National Prevalence of Diabetes and Barriers to Care Among U.S. Farmworkers and Association With Migrant Worker Status

OBJECTIVE

To quantify the prevalence of diabetes and barriers to care among U.S. migrant farmworkers (i.e., those who travel from their permanent residence for seasonal farmwork).

RESEARCH DESIGN AND METHODS

Age-adjusted prevalence of self-reported diabetes and barriers to care were calculated among adult U.S. farmworkers from 2008 to 2017 National Agricultural Workers Surveys.

RESULTS

Among 16,913 farmworkers, 30.7% reported one or more barriers to care, most often due to cost. Age-adjusted self-reported prevalence of diabetes was 13.51% (95% CI 10.0-17.1) among migrant farmworkers and 10.8% (95% CI 9.0-12.6) among nonmigrant farmworkers with access to health care. Migrant farmworkers without recent health care had 83% lower odds of reporting known diabetes (adjusted odds ratio 0.17; 95% CI 0.06-0.54) compared with nonmigrant farmworkers, likely because of poor health care access and/or a healthy worker effect.

CONCLUSIONS

Many migrant farmworkers face barriers to care, which may lead to significant underdiagnosis of diabetes in this vulnerable population.

Patient-reported outcome measures in diabetes outpatient care: a scoping review

BACKGROUND

Patient-reported outcome (PRO) measures are increasingly used in clinical diabetes care to increase patient involvement and improve healthcare services. The objectives were to identify instruments used to measure PROs in outpatient diabetes clinics and to investigate the use of these PRO measures alongside the experiences of patients and healthcare personnel in a clinical setting.

RESEARCH DESIGN AND METHODS

A scoping review was conducted according to the framework of Arksey and O'Malley with scoping searches of Cinahl, EMBASE, Medline and Health and Psychosocial Instruments. Studies reporting on adults with diabetes in a clinical setting where the PRO measure response directly affected patient care were eligible for inclusion.

RESULTS

In total, 35 197 citations were identified, of which 7 reports presenting 4 different PRO measures were included in the review. All four of the included items measured psychosocial aspects of diabetes, and three included elements of the Problem Areas in Diabetes scale. All the patients were satisfied with the use of PRO measures in clinical care, whereas the level of satisfaction among healthcare personnel with PRO measures varied within and among studies.

CONCLUSIONS

The limited number of eligible studies in this review suggests that research on PRO measures for diabetes outpatient care is scarce. Patients welcome the opportunity to express their concerns through the systematic collection of PRO measures, and some healthcare personnel value the broader insight that PRO measures provide into the impact of diabetes on patients' lives. However, the heterogeneity among services and among patients challenges the implementation of PRO measures. Research is needed to explore how PRO measures in clinical outpatient care affect healthcare personnel workflow.

REVIEW REGISTRATION

https://doi.org/10.17605/OSF.IO/46AHC.

Clinical outcomes of a digitally supported approach for self-management of type 2 diabetes mellitus

Background

Self-management of Type 2 diabetes mellitus (T2D) is challenging. Regular self-monitoring of blood glucose and healthy lifestyles are required to improve glycometabolic control, thus delaying diabetes complications, and reducing hospitalizations. Digital technologies can empower patients in their disease management promoting self-management and motivation to change behaviors. We report the results of an exploratory trial aimed at evaluating the metabolic outcomes of using digital solutions for T2D self-management developed in the ProEmpower project, a European Commission funded Pre-Commercial Procurement.

Methods

Two digital solutions, DM4All and DiaWatch, which were codesigned with providers, patients, and caregivers, enabled the collection of clinical parameters by the patient using a smartphone integrated with the medical devices (glucometer, sphygmomanometer, scale, smart watch for heart rate monitoring and step counter). Data were automatically sent to the shared care plan allowing professionals to monitor adherence to treatment, set goals, and communicate more effectively with patients. At baseline and after an average follow-up of 8 months, glycosylated hemoglobin (HbA1c), body weight, blood pressure, and blood lipids were measured in 100 T2D patients using the ProEmpower solutions across different diabetes centers in Campania Region, age 45-79  years, both genders, and compared with a Control cohort of T2D patients (n = 100) with similar clinical characteristics and followed for a comparable period of observation in the same centers.

Results

At baseline, the ProEmpower participants and the Control subjects were on average overweight, with a similar BMI in the two cohorts, and mean HbA1c was at acceptable levels (around 7.0%). After the 8 month exploratory trial, body weight, HbA1c, systolic and diastolic blood pressure, and plasma and LDL-cholesterol significantly decreased in the ProEmpower participants compared to baseline (p < 0.05 for all). The changes in systolic and diastolic blood pressure, and plasma and LDL-cholesterol were significantly different from those observed in the Control cohort (p < 0.05 for all).

Conclusion

This pilot study showed positive effects on metabolic outcomes relevant to cardiovascular risk in T2D of adopting digital telemedicine self-monitoring solutions based on automation of measurements and coaching on healthy lifestyles promotion.

Metabolic-Related Index to Predict Post-Transplantation Diabetes Mellitus After Kidney Transplantation

Metabolic-related markers are novel tools for assessing insulin resistance. Early identification of post-transplantation diabetes mellitus (PTDM) before hyperglycemia can be helpful to attenuate the rapid development of diabetic complications. This article aims to explore the convenient and inexpensive values of metabolic-related markers, including TyG, TyG-BMI, TG/HDL-C, and non-HDL-C/HDL-C for predicting PTDM. The data of 191 kidney transplant recipients in our center were collected retrospectively. The association between TyG, TyG-BMI, TG/HDL-C, non-HDL-C/HDL-C and the risk of PTDM was examined by the area under the curve and logistic regression analyses. During 6 months follow-up, 12.04% of KT recipients developed PTDM, and significantly higher values of TyG-BMI, TyG, and non-HDL-C/HDL-C was found in patients with PTDM than in nondiabetic patients, especially among the recipients taking tacrolimus, regardless of gender. The incidence of PTDM increased along with the values of TyG or TyG-BMI. After adjusting for multiple potential factors, recipients with the highest trisector of TyG or TyG-BMI still had a higher risk of PTDM morbidity. In conclusion, TyG, TyG-BMI, TG/HDL-C and non-HDL-C/HDL-C can be used as cost-effective and promising monitors to identify individuals at high risk of PTDM, and TyG-BMI was the best alternative marker among the four markers.

Reducing the Cost of Diabetes Care with Telemedicine, Smartphone, and Home Monitoring

The effect of an increasing diabetes population has resulted in escalated costs and overburdened physicians. The increase in cost is not due to the disease per se, but because of its largely preventable complications. Patient-friendly technologies are proven to significantly reduce complications and thereby cost, but seldom practised. Telemedicine is increasingly being utilized in diabetology to improve access to health care, quality of care, and clinical/psychosocial outcomes in patients with diabetes (PWD). In PWD, patient-physician interactions are essential for improving health outcomes and preventing long-term complications. Smartphones are one of the basic modalities for telemedicine application. Mobile phone messaging applications, including text messaging and multimedia message service, could offer a convenient and cost-effective way to support desirable health behaviors. There are diabetes-related mobile apps mainly focusing on self-management of diabetes, lifestyle modification, and medication adherence motivation. With the widespread availability of high-speed Internet, remote monitoring has also become popular. Home monitoring of blood glucose and blood pressure, wearable devices, and continuous glucose monitoring also play a vital role in bringing down the long‑term vascular complications of diabetes and thereby reduce the overall cost and improve the quality of life of patients. There are hundreds of tech platforms for diabetes management, of which only a few with proven efficacy and safety are recommended by physicians.

Lower Extremity Nerve Conduction Abnormalities in Vietnamese Patients with Type 2 Diabetes: A Cross-Sectional Study on Peripheral Neuropathy and Its Correlation with Glycemic Control and Renal Function

Peripheral neuropathy is a common complication of type 2 diabetes mellitus (T2DM) that results in nerve conduction abnormalities. This study aimed to investigate the parameters of nerve conduction in lower extremities among T2DM patients in Vietnam. A cross-sectional study was conducted on 61 T2DM patients aged 18 years and older, diagnosed according to the American Diabetes Association’s criteria. Data on demographic characteristics, duration of diabetes, hypertension, dyslipidemia, neuropathy symptoms, and biochemical parameters were collected. Nerve conduction parameters were measured in the tibial and peroneal nerves, including peripheral motor potential time, response amplitude M, and motor conduction speed, as well as sensory conduction in the shallow nerve. The study found a high rate of peripheral neuropathy among T2DM patients in Vietnam, with decreased conduction rate, motor response amplitude, and nerve sensation. The incidence of nerve damage was highest in the right peroneal nerve and left peroneal nerve (86.7% for both), followed by the right tibial nerve and left tibial nerve (67.2% and 68.9%, respectively). No significant differences were found in the rate of nerve defects between different age groups, body mass index (BMI) groups, or groups with hypertension or dyslipidemia. However, a statistically significant association was found between the rate of clinical neurological abnormalities and the duration of diabetes (p < 0.05). Patients with poor glucose control and/or decreased renal function also had a higher incidence of nerve defects. The study highlights the high incidence of peripheral neuropathy among T2DM patients in Vietnam and the association between nerve conduction abnormalities and poor glucose control and/or decreased renal function. The findings underscore the importance of early diagnosis and management of neuropathy in T2DM patients to prevent serious complications.

The Effectiveness of an eHealth Family-Based Intervention Program in Patients With Uncontrolled Type 2 Diabetes Mellitus (T2DM) in the Community Via WeChat: Randomized Controlled Trial

BACKGROUND

Intervention based on family support and risk perception can enhance type 2 diabetes mellitus (T2DM) patients' self-care activities. In addition, eHealth education is considered to improve family members' support for patients with T2DM. However, there is little evidence from rigorously designed studies on the effectiveness of an intervention combining these approaches.

OBJECTIVE

This randomized controlled trial (RCT) aimed to assess the effectiveness of an eHealth family-based health education intervention for patients with T2DM to improve their glucose control, risk perception, and self-care behaviors.

METHODS

This single-center, 2-parallel-group RCT was conducted between 2019 and 2020. Overall, 228 patients were recruited from Jiading District, Shanghai, and randomly divided into intervention and control groups. The intervention group received an eHealth family intervention based on community management via WeChat, whereas the control group received usual care. The primary outcome was the glycated hemoglobin (HbA1c) level of the patients with T2DM, and the secondary outcomes were self-management behavior (general and specific diet, exercise, blood sugar testing, foot care, and smoking), risk perception (risk knowledge, personal control, worry, optimism bias, and personal risk), and family support (supportive and nonsupportive behaviors). A 2-tailed paired-sample t test was used to compare the participants at baseline and follow-up within the control and intervention groups. An analysis of covariance was used to measure the intervention effect.

RESULTS

In total, 225 patients with T2DM were followed up for 1 year. After intervention, they had significantly lower HbA1c values (β=-.69, 95% CI -0.99 to -0.39; P<.001). They also had improved general diet (β=.60, 95% CI 0.20 to 1.00; P=.003), special diet (β=.71, 95% CI 0.34 to 1.09; P<.001), blood sugar testing (β=.50, 95% CI 0.02 to 0.98; P=.04), foot care (β=1.82, 95% CI 1.23 to 2.42; P<.001), risk knowledge (β=.89, 95% CI 0.55 to 1.24; P<.001), personal control (β=.22, 95% CI 0.12 to 0.32; P<.001), worry (β=.24, 95% CI 0.10 to 0.39; P=.001), optimism bias (β=.26, 95% CI 0.09 to 0.43; P=.003), and supportive behaviors (β=5.52, 95% CI 4.03 to 7.01; P<.001).

CONCLUSIONS

The eHealth family-based intervention improved glucose control and self-care activities among patients with T2DM by aiding the implementation of interventions to improve T2DM risk perceptions among family members. The intervention is generalizable for patients with T2DM using health management systems in community health centers.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900020736; https://www.chictr.org.cn/showprojen.aspx?proj=31214.

Evaluation of pharmacist consults within a collaborative enhanced primary care team model to improve diabetes care

BACKGROUND

An enhanced primary care team model was implemented to provide proactive, longitudinal care to patients with diabetes, grounded in close partnership between primary care providers (PCPs), nurses, and Medication Management Services (MMS) pharmacists. The purpose of this study is to evaluate the impact of the MMS pharmacist involvement in the enhanced primary care model for patients with diabetes.

METHODS

This retrospective cohort study compared the quality of diabetes care between patients referred to a pharmacist and propensity score matched controls who were not. Eligible patients were adults (age 18 to 75 years) enrolled in the enhanced primary care team process who did not meet at least one of four diabetes quality indicators at 13 Mayo Clinic Rochester primary care practice locations. The intervention examined was asynchronous e-consults by pharmacists affiliated with the primary care practice.

MAIN MEASURES

The primary outcome was change in the proportion of patients meeting the composite of four diabetes treatment goals (D4), including hemoglobin A1c (HbA1c) control, blood pressure control, aspirin use, and statin use at six months from enrollment among patients who received pharmacist intervention compared to matched patients who did not. Secondary outcomes were each of the D4 goal individually.

RESULTS

The proportion of patients meeting the D4 increased with pharmacist e-consults (N = 85) compared to matched controls with no review (N = 170) (27% vs 7.0%, p<0.001). The change in patients meeting treatment goals of HbA1c (12.9% vs 4.1%, p = 0.020), blood pressure (9.4% vs 2.4%, p = 0.023), aspirin use (10.6% vs 2.9%, p = 0.018), and statin use (17.6% vs -1.2%, p<0.001) all increased with pharmacist e-consults.

CONCLUSIONS

Pharmacist engagement in the enhanced primary care team improved diabetes management. This supports the inclusion and utilization of pharmacists in multidisciplinary efforts to improve diabetes care.

Antihyperglycemic Effects of Annona cherimola Miller and the Flavonoid Rutin in Combination with Oral Antidiabetic Drugs on Streptozocin-Induced Diabetic Mice

Ethanolic extract obtained from Annona cherimola Miller (EEAc) and the flavonoid rutin (Rut) were evaluated in this study to determine their antihyperglycemic content, % HbA1c reduction, and antihyperlipidemic activities. Both treatments were evaluated separately and in combination with the oral antidiabetic drugs (OADs) acarbose (Aca), metformin (Met), glibenclamide (Gli), and canagliflozin (Cana) in acute and subchronic assays. The evaluation of the acute assay showed that EEAc and Rut administered separately significantly reduce hyperglycemia in a manner similar to OADs and help to reduce % HbA1c and hyperlipidemia in the subchronic assay. The combination of EEAc + Met showed the best activity by reducing the hyperglycemia content, % HbA1c, Chol, HDL-c, and LDL-c. Rutin in combination with OADs used in all treatments significantly reduced the hyperglycemia content that is reflected in the reduction in % HbA1c. In relation to the lipid profiles, all combinate treatments helped to avoid an increase in the measured parameters. The results show the importance of evaluating the activity of herbal remedies in combination with drugs to determine their activities and possible side effects. Moreover, the combination of rutin with antidiabetic drugs presented considerable activity, and this is the first step for the development of novel DM treatments.

Monitoring of blood glucose after pediatric kidney transplantation: a longitudinal cohort study

BACKGROUND

Glucose metabolism after kidney transplantation (KT) is highly dynamic with the first post-transplantation year being the most critical period for new-onset diabetes after transplantation (NODAT) occurrence. The present study aimed to analyze dynamics of glucose metabolism and report incidence/risk factors of abnormal glycemic state during the first year after KT in children.

METHODS

Twenty-one consecutive freshly transplanted pediatric kidney transplant recipients (KTRs) were assessed for fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) weekly for 4 weeks, then every 3 months for 1 year.

RESULTS

Interpretation of OGTT test showed normal glucose tolerance (NGT) in 6 patients (28.6%) while 15 (71.4%) experienced impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) at any time point of monitoring. Seven patients had NODAT, for which three needed insulin therapy. Hyperglycemia onset was 7.8 ± 13.12 weeks (median (range) = 1 (0-24) week) after KT. Percent of patients with abnormal OGTT was significantly more than that of IFG (38.1% vs. 71.4%, p = 0.029). Patients with abnormal glycemic state had significantly elevated trough tacrolimus levels at 6 months (p = 0.03). Glucose readings did not correlate with steroid doses nor rejection episodes while positively correlating with tacrolimus doses at 3 months (p = 0.02, CC = 0.73) and 6 months (p = 0.01, CC = 0.63), and negatively correlating with simultaneous GFR at 9 months (p = 0.04, CC =  - 0.57).

CONCLUSIONS

Up to two thirds of pediatric KTRs (71.4%) experienced abnormal glycemic state at some point with peak incidence within the first week up to 6 months after KT. OGTT was a better tool for monitoring of glucose metabolism than FPG. Abnormal glycemic state was induced by tacrolimus and adversely affected graft function. A higher resolution version of the Graphical abstract is available as Supplementary information.

Remnant cholesterol is independently asssociated with an increased risk of peripheral artery disease in type 2 diabetic patients

BACKGROUND

Remnant cholesterol (RC) has been correlated with a higher risk of atherosclerosis. It has been confirmed that in the general population, an elevated RC level is related to a 5-fold higher risk of peripheral arterial disease (PAD). Diabetes is one of the strongest risk factors for PAD development. However, the association between RC and PAD in the specific population of type 2 diabetes mellitus (T2DM) has not been investigated. Herein, the correlation was investigated between RC and PAD in T2DM patients.

METHODS

In the retrospective study, the hematological parameter data of 246 T2DM patients without PAD (T2DM - WPAD) and 270 T2DM patients with PAD (T2DM - PAD) was collected. Differences in RC levels between the two groups were compared, and the association between RC and PAD severity was examined. Multifactorial regression was used to determine whether RC was a significant contributor to the development of T2DM - PAD. The diagnostic potential of RC was tested using receiver operating characteristic (ROC) curve.

RESULTS

The RC levels in T2DM - PAD individuals were considerably greater than in T2DM - WPAD individuals (P < 0.001). RC had a positive correlation with disease severity. Further, multifactorial logistic regression analyses found that elevated RC levels were a major contributor to T2DM - PAD (P < 0.001). The area under the curve (AUC) of the RC for T2DM - PAD patients was 0.727. The cut-off value of RC was 0.64 mmol/L.

CONCLUSION

The RC levels were higher in T2DM - PAD patients, and were independently linked with its severity. Diabetic patients with RC levels > 0.64 mmol/L had an elevated risk of developing PAD.

Combination model of neutrophil to high-density lipoprotein ratio and system inflammation response index is more valuable for predicting peripheral arterial disease in type 2 diabetic patients: A cross-sectional study

BACKGROUND

Neutrophil/high-density lipoprotein (HDL) ratio (NHR), monocyte/HDL ratio (MHR), lymphocyte/HDL ratio (LHR), platelet/HDL ratio (PHR), systemic immune-inflammation index (SII), system inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI) have been recently investigated as novel inflammatory markers. Herein, the correlation was investigated between these inflammatory biomarkers and peripheral arterial disease (PAD) in type 2 diabetes mellitus (T2DM) patients.

METHODS

In this retrospective observational study, the hematological parameter data of 216 T2DM patients without PAD (T2DM-WPAD) and 218 T2DM patients with PAD (T2DM-PAD) at Fontaine stages II, III or IV stage had been collected. Differences in NHR, MHR, LHR, PHR, SII, SIRI, and AISI were analyzed, and receiver operating characteristic (ROC) curves were used to analyze the diagnostic potential of these parameters.

RESULTS

The levels of NHR, MHR, PHR, SII, SIRI and AISI in T2DM-PAD patients were significantly higher than in T2DM-WPAD patients (P < 0.001). They were correlated with disease severity. Further, multifactorial logistic regression analyses showed that higher NHR, MHR, PHR, SII, SIRI, and AISI might be independent risk factors for T2DM-PAD (P < 0.001). The areas under the curve (AUCs) of the NHR, MHR, PHR, SII, SIRI, and AISI for T2DM-PAD patients was 0.703, 0.685, 0.606, 0.648, 0.711, and 0.670, respectively. The AUC of the NHR and SIRI combined model was 0.733.

CONCLUSION

The levels of NHR, MHR, PHR, SII, SIRI, and AISI were higher in T2DM-PAD patients, and they were independently linked with its clinical severity. The combination model of NHR and SIRI was most valuable for predicting T2DM - PAD.

Metformin Improves Burn Wound Healing by Modulating Microenvironmental Fibroblasts and Macrophages

Metformin, a biguanide, exerts different functions through various signaling pathways. In order to investigate the function and mechanism of metformin in burn wounds, we established burn rat models, subcutaneously injected metformin to treat the wounds, and observed the morphologies and the expression of collagen I, collagen III, fibronectin, and pro-inflammatory markers. In vitro experiments were performed to investigate the effects of metformin on the proliferation, migration, and collagen I synthesis of the mouse embryonic fibroblast (NIH 3T3) cell line and on the proliferation, apoptosis, and immune response of the mouse mononuclear macrophage (RAW 264.7) cell line. Finally, we studied the regulatory effects of metformin on a co-culture of RAW 264.7/NIH 3T3 cells. We found that 100 mM of metformin reduced dermal thickness, collagen I deposition, and mRNA expression of IL1β and CCL2 in rat burn wounds. In vitro experiments revealed that metformin inhibited the proliferation of NIH 3T3 and RAW 264.7 cells. Metformin attenuated NIH 3T3 cell migration via the AMPK/mTOR pathway and attenuated collagen I synthesis through the TGFβ1/Smad3 pathway. Metformin inhibited the apoptosis of RAW 264.7 cells induced by 10 μg/mL LPS. Metformin downregulated the mRNA expression of IL1β and CCL2 in RAW 264.7 cells under 1 μg/mL LPS induction by inhibiting NF-κB p65 phosphorylation. In a RAW 264.7/NIH 3T3 co-culture, metformin attenuated collagen I synthesis in NIH 3T3 cells by inhibiting RAW 264.7 paracrine secretion of TGF-β1. This provides new evidence related to the development of metformin for potentially improving burn wound healing.

Liver fibrosis is associated with impaired bone mineralization and microstructure in obese individuals with non-alcoholic fatty liver disease

BACKGROUND AND PURPOSE

Chronic liver diseases are associated with increased bone fracture risk, mostly in end-stage disease and cirrhosis; besides, data in non-alcoholic fatty liver disease (NAFLD) are limited. Aim of this study was to investigate bone mineralization and microstructure in obese individuals with NAFLD in relation to the estimated liver fibrosis.

METHODS

For this cross-sectional investigation, we analyzed data from 1872 obese individuals (44.6 ± 14.1 years, M/F: 389/1483; BMI: 38.3 ± 5.3 kg/m²) referring to the Endocrinology outpatient clinics of Sapienza University, Rome, Italy. Participants underwent clinical work-up, Dual-Energy X-ray Absorptiometry for assessing bone mineral density (BMD) and microarchitecture (trabecular bone score, TBS). Liver fibrosis was estimated by Fibrosis Score 4 (FIB-4). Serum parathyroid hormone (PTH), 25(OH) vitamin D, osteocalcin and IGF-1 levels were measured.

RESULTS

Obese individuals with osteopenia/osteoporosis had greater FIB-4 than those with normal BMD (p < 0.001). FIB-4 progressively increased in presence of degraded bone microarchitecture (p < 0.001) and negatively correlated with the serum osteocalcin (p < 0.001) and IGF-1 (p < 0.001), which were both reduced in presence of osteopenia/osteoporosis. FIB-4 predicted IGF-1 reduction in multivariable regression models adjusted for confounders (β: - 0.18, p < 0.001). Higher FIB-4 predicted bone fragility with OR 3.8 (95%C.I:1.5-9.3); this association persisted significant after adjustment for sex, age, BMI, diabetes, smoking status and PTH at the multivariable logistic regression analysis (OR 1.91 (95%C.I:1.15-3.17), p < 0.01), with AUROC = 0.842 (95%C.I:0.795-0.890; p < 0.001).

CONCLUSION

Our data indicate the presence of a tight relation between NAFLD-related liver fibrosis, lower bone mineral density and degraded microarchitecture in obese individuals, suggesting potential common pathways underlying liver and bone involvement in obesity and insulin resistance-associated disorders.

Determinants of response to the glucagon-like peptide-1 receptor agonists in a type 2 diabetes population in the real-world

AIMS

To identify clinical predictors associated with a response in terms of glycemic control and weight loss in patients with type 2 diabetes treated with glucagon-like peptide-1 receptor agonists (GLP-1RAs).

METHODS

A retrospective observational study was performed with real-world databases in primary care. Patients with type 2 diabetes-initiated treatment with GLP-1RAs during the study period, and response to GLP-1RAs were determined six months from treatment initiation. An optimal glycated hemoglobin (HbA1c) or weight response was defined as a reduction of ≥ 1% or ≥ 3%, respectively. A "great" response was defined as both an optimal HbA1c and weight response. Bivariate and multivariate analyses with intention-to-treat were performed.

RESULTS

A sample of 2944 patients with type 2 diabetes was recruited. Higher HbA1c at baseline was the main clinical predictor of an optimal HbA1c response (odds ratio [OR]: 2.30, 95% confidence interval [CI]: 1.96-2.71 in men and OR: 2.03, 95% CI: 1.76-2.33 in women). Treatment without insulin at baseline was associated with a greater weight reduction in men (OR: 2.50, 95% CI: 1.41-4.44). Older age and a higher weight at baseline were related with this in women (OR: 1.02, 95% CI: 1.00-1.05 and OR: 1.01, 95% CI: 1.00-1.02, respectively).

CONCLUSIONS

A high HbA1c at baseline and previous non-insulin therapy were the main predictors of a greater response (optimal HbA1c and weight response) to GLP1ra in both men and women. This may aid in treatment decision-making before initiating treatment with GLP-1RAs.

Applications and Pharmacological Properties of Cactus Pear (Opuntia spp.) Peel: A Review

Nowadays, there is a growing interest in the exploitation of by-products from fruits and vegetables, generated from industrial processing or human feeding. Residues of popularly consumed fruits such as orange, lemon, banana, pomegranate, among others, have been widely described and studied; however, cactus pear (Opuntia spp.) residues, as a locally consumed product, have been forgotten. The whole fruit can be divided into the edible portion (pulp) and the non-edible portion (seeds and peel). Several studies mainly focus on the characteristics of the edible portion or in the whole fruit, ignoring by-products such as peels, which are rich in compounds such as phenols, flavonoids and dietary fiber; they have also been proposed as an alternative source of lipids, carbohydrates and natural colorants. Some uses of the peel have been reported as a food additives, food supplements, as a source of pectins and for wastewater treatment; however, there have not been any deep investigations of the characteristics and potential uses of the cactus pear peel (CPP). The aim of the present paper is to provide an overview of the current research on CPP. CPP has many bio-active compounds that may provide health benefits and may also be useful in pharmaceutical, food and manufacturing industries; however, greater research is needed in order to gain thorough knowledge of the possibilities of this by-product.

Lean Implementation for Graduating Optimally Controlled Stable Type 2 Diabetics from Endocrine Specialty Clinic Back to Primary Care

INTRODUCTION

Endocrine specialty clinics (SCs) are occupied by a high percentage of stable follow-up patients, limiting access to new patients with greater needs.

AIM

Feasibility project to improve access to diabetes SC by reducing the number of stable optimally controlled follow-up type 2 diabetic patients.

SETTING

M Health Fairview (MHFV), a hybrid network of University of Minnesota academic and Fairview Health community hospitals and clinics with affiliated providers.

PROGRAM DESCRIPTION

A team-based lean methodology quality improvement graduation program including medical assistants, nurses, physicians, and a compact with primary care (PC) was used to identify within the Endocrine clinic population the graduation-eligible optimally controlled stable type 2 diabetic patients, acclimate them to the graduation concept, engage in shared decision-making, and transition them back to PC with a warm hand-off and graduation certificate.

PROGRAM EVALUATION

Seventeen percent (58/341) of eligible patients with optimally controlled diabetes graduated by 6 months, ranging between 0 and 83% per week.

DISCUSSION

The innovation and feasibility of opening SC access through the use of a team-based graduation program to transfer stable diabetes patients back to their home clinic was demonstrated. This innovation has the potential to support health system triage of new patients to limited access specialty care.

Efficacy of Self-Management on Glucose Control in Type 2 Diabetes Mellitus Patients Treated with Insulin

Diabetes mellitus (DM) is a chronic metabolic disease. If blood glucose is poorly controlled, it will cause a variety of chronic complications. Therefore, the issue of healthcare in diabetic patients is a problem that cannot be ignored. In this study, we aim to investigate the correlation between sociodemographic characteristics, self-management, and glycated hemoglobin (HbA1c) values in patients with type 2 diabetes treated with insulin. A total of 300 type 2 diabetic patients treated with insulin were enrolled. Type 2 diabetic patients treated with insulin had a significant negative correlation of HbA1c value to self-management total score. The lower the HbA1c value, the better the self-management of type 2 diabetic patients treated with insulin is. It is recommended that scale assessment tools be used to identify problems, improve the self-management ability of type 2 diabetic patients, and problem solve in patients in order to facilitate the effectiveness of blood glucose control of type 2 diabetic patients.

Effect of metformin monotherapy and dual or triple concomitant therapy with metformin on glycemic control and lipid profile management of patients with type 2 diabetes mellitus

Background

In this study, we aimed to compare the effects of metformin-based dual therapy versus triple therapy on glycemic control and lipid profile changes in Taiwanese patients with type 2 diabetes mellitus (T2DM).

Methods

In total, 60 patients were eligible for participation in this study. Patients received at least 24 months of metformin monotherapy, dual therapy, or triple therapy with metformin plus linagliptin (a dipeptidyl peptidase 4 (DPP-4) inhibitor) or dapagliflozin (a sodium-glucose cotransporter-2 (SGLT2) inhibitor). Blood samples were collected from each patient, followed by evaluation of changes in their blood glucose control and lipid profile-related markers.

Results

A combination of metformin and DPP4 and SGLT2 inhibitor therapy more effectively reduced low-density lipoprotein cholesterol (LDL-C) (p = 0.016) than metformin monotherapy. A combination of metformin and DPP4 and SGLT2 inhibitor therapy more effectively improved total cholesterol (Chol, p = 0.049) and high-density lipoprotein cholesterol (HDL-C) than metformin monotherapy (p = 0.037). Metformin plus linagliptin dual therapy was more effective than metformin monotherapy in reducing glycosylated hemoglobin (HbA1C, p = 0.011). Patients who received a combination of linagliptin and empagliflozin showed a significant reduction in their fasting blood glucose (p = 0.019), HbA1c (p = 0.036), and Chol (p = 0.010) compared with those who received linagliptin dual therapy. Furthermore, patients who received metformin plus dapagliflozin and saxagliptin showed significantly reduced Chol (p = 0.011) and LDL-C (p = 0.035) levels compared with those who received metformin plus dapagliflozin.

Conclusion

In conclusion, dual therapy with metformin and linagliptin yields similar glycemic control ability to triple therapy. Among metformin combination triple therapy, triple therapy of empagliflozin and linagliptin might have a better glycemic control ability than dual therapy of linagliptin. Moreover, Triple therapy of dapagliflozin and saxagliptin might have a better lipid control ability than dual therapy of dapagliflozin.

Effect of metformin on adverse outcomes in T2DM patients: Systemic review and meta-analysis of observational studies

Background

The cardiovascular protection effect of metformin on patients with type 2 diabetes mellitus (T2DM) remains inconclusive. This systemic review and meta-analysis were to estimate the effect of metformin on mortality and cardiovascular events among patients with T2DM.

Methods

A search of the Pubmed and EMBASE databases up to December 2021 was performed. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled by a random-effects model with an inverse variance method.

Results

A total of 39 studies involving 2473009 T2DM patients were adopted. Compared to non-metformin therapy, the use of metformin was not significantly associated with a reduced risk of major adverse cardiovascular event (MACE) (HR = 1.06, 95%CI 0.91–1.22; I² = 82%), hospitalization (HR = 0.85, 95%CI 0.64–1.13; I² = 98%), heart failure (HR = 0.86, 95%CI 0.60–1.25; I² = 99%), stroke (HR = 1.16, 95%CI 0.88–1.53; I² = 84%), and risk of AMI (HR = 0.88, 95%CI 0.69–1.14; I² = 88%) in T2DM patients. Metformin was also not associated with significantly lowered risk of MACE compared to dipeptidyl peptidase-4 inhibitor (DPP-4i) in T2DM patients (HR = 0.95, 95%CI 0.73–1.23; I² = 84%).

Conclusions

The effect of metformin on some cardiovascular outcomes was not significantly better than the non-metformin therapy or DPP-4i in T2DM patients based on observational studies.

Associations of long-term ambient air pollution and traffic-related pollution with blood pressure and hypertension defined by the different guidelines worldwide: the CHCN-BTH study

The assessment of the generalization of the strict hypertension definition in the 2017 ACC/AHA Hypertension Guideline from environmental condition remains sparse. The aims of this study are to investigate and compare the associations of ambient air pollution and traffic-related pollution (TRP) with hypertension defined by the different criteria. A total of 32,135 participants were recruited from the baseline survey of the CHCN-BTH in 2017. We defined hypertension as SBP/DBP ≥ 140/90 mmHg according to the hypertension guidelines in China, Japan, Europe and ISH (traditional criteria) and defined as SBP/DBP ≥ 130/80 mmHg according to the 2017 ACC/AHA Hypertension Guideline (strict criteria). A two-level generalized linear mixed models were applied to investigate the associations of air pollutants (i.e. PM_2.5, SO₂, NO₂) and TRP with blood pressure (BP) measures and hypertension. Stratified analyses and two-pollutant models were also performed. The stronger associations of air pollutants were found in the hypertension defined by the strict criteria than that defined by the traditional criteria. The ORs per an IQR increase in PM_2.5 were 1.17 (95% CI: 1.09, 1.25) for the strict criteria and 1.14 (95% CI: 1.06, 1.23) for the traditional criteria. The similar conditions were also observed for TRP. The above results were robust in both stratified analyses and two-pollutant models. Our study assessed the significance of the hypertension defined by the strict criteria from environmental aspect and called attention to the more adverse effects of air pollution and TRP on the earlier stage of hypertension.

A machine learning approach identifies modulators of heart failure hospitalization prevention among patients with type 2 diabetes: A revisit to the ACCORD trial

BACKGROUND

To examine patient characteristics that may modulate the heterogeneous treatment effect of intensive systolic blood pressure control (SBP) and intensive glycemic control on incident heart failure (HF) risk in people with type 2 diabetes.

METHODS

We analyzed 10,251 participants from the ACCORD glucose trial, and 4733 from the SBP sub-trial separately. We applied a robust machine-learning (ML) algorithm, namely the causal forest/causal tree analysis, to each trial to identify participants' characteristics that modulate the effectiveness of each trial intervention.

RESULTS

Diastolic blood pressure (DBP) was found to interact with intensive glycemic control and impact outcomes. An increased HF risk associated with intensive glycemic control (absolute risk change (ARC): 2.28 %, 95 % confidence interval (CI): 0.69 % to 3.90 %; relative risk (RR):1.57, 95 % CI: 1.15 to 2.20; P < 0.05) was observed in individuals with baseline DBP at the lowest tertile (45-69 mmHg), while no changes in HF risk associated with intensive glycemic control were observed in individuals with baseline DBP at the middle (70-79 mmHg) and the highest tertiles (80-100 mmHg). Liver function was identified as a modulator of intensive BP control, and baseline Alanine transaminase (ALT) level was a sensitive marker for the modulating effect. Only individuals with baseline ALT at the lowest tertile (8-19 mg/dl) benefited from the intensive BP control for HF prevention (ARC: -1.95 %, 95 % CI: -4.06 % to 0.11 %; RR:0.62. 95 % CI: 0.27 to 0.94; P < 0.05).

CONCLUSIONS

Our study is the first to observe and quantify the potential synergistic harmful effect when low DBP was combined with an intensive blood glucose intervention. Recognizing these may help clinicians develop a more precise approach to such treatments, thus increasing the efficiency and outcomes of diabetes treatments.

Perceived risk for diabetes among U.S. adults with undiagnosed prediabetes

The purpose was to examine the degree to which perceived risk for diabetes differed by race and ethnicity among U.S. adults with undiagnosed prediabetes. The study was a cross-sectional analysis of data from 4005 participants (aged ≥20 years) in the National Health and Nutrition Examination Survey (NHANES) program between 2011 and 2018. Individuals with prediabetes were identified using glycohemoglobin (HbA_1c) data. Logistic regression was used to estimate the association between race and ethnicity and perceived risk of diabetes while adjusting for age and sex, educational level, family history of diabetes, BMI, and healthcare factors (health insurance coverage and routine place to go for healthcare). Nearly three-quarters (71.8%) of adults with undiagnosed prediabetes reported no perceived risk for diabetes. Rates of perceived risk for diabetes did not change significantly in any racial and ethnic groups from 2011 to 12 to 2017-18. In models adjusted for individual characteristics, identifying as Non-Hispanic Black was associated with a 34% higher likelihood of reporting no perceived risk compared to identifying as Non-Hispanic White (OR 1.34, 95% CI:1.03-1.74). Identifying as Hispanic was associated with a 29% higher likelihood of reporting no perceived risk compared to identifying as Non-Hispanic White (OR 1.29, 95% CI: 1.01, 1.66). Healthcare factors may have less influence on diabetes risk perception. Future public health efforts should improve diabetes risk communication efforts across racial and ethnic groups, emphasizing Non-Hispanic Black and Hispanic populations.

Effectiveness of restricted diet with a plate in patients with type 2 diabetes: A randomized controlled trial

BACKGROUND

In view of the complexity of dietary and nutritional education for most patients with type 2 diabetes mellitus (T2DM), a simplified approach called the "restricted diet with a plate" or "plate model" is recommended.

PURPOSE

To evaluate whether the plate model can effectively improve glycemic control and cardiovascular risk markers in type 2 diabetes mellitus (T2DM), while reducing the time devoted to education and avoiding weight gain.

METHODS

The study was a randomized, multicenter, controlled study, conducted between October 2018 and October 2019, among patients with T2DM living in Nanjing. The study included 419 participants who were randomly divided into a plate group and a counting group. The plate model included three components: a low-literacy, color leaflet containing the explanation and composition of the plate model, health education, and medical visits. Patients in the counting group received health education, group medical visits, and a paper booklet containing traditional carbohydrate counting education. Primary outcomes were glycemic control and weight.

RESULTS

Participants in the plate model reduced HbA_1c by 0.7% in the first three months, and reduced to a greater extent at six months (1.44%), but this was not sustained, and HbA_1c increased slightly over the following six months. Fasting plasma glucose (FPG) and 2-h postprandial glucose (2hPG) values were significantly reduced at the endpoint in the plate model (9.25 ± 1.72% vs. 7.44 ± 0.88%, P = 0.008; 12.07 ± 2.94 vs. 8.35 ± 1.99%; P = 0.004); however, the 2hPG values decreased most significantly. Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels decreased significantly in the plate group, which occurred at six months and lasted for 12 months. In the first three months, the average weight loss in the plate group was 1.2 kg/month (95% CI 0.92-1.48), and in the fourth to twelfth months, the average weight gain was 0.21 kg/month (95% CI 0.08-0.34). There was significant difference in education time between the groups (17.3 ± 4.42 vs. 38.6 ± 12.63; P < 0.001).

CONCLUSIONS

The plate model is at least as effective as the counting model over the short term for glycemic control and perhaps even better for weight and lipid control. Plate model has the potential to improve education of those with low health literacy by reducing reading demands.

Rating the importance of outcomes from diabetes trials. A survey of patients' and doctors' opinions

Purpose

To investigate and compare how patients with diabetes mellitus and doctors rate the importance of outcomes used as part of composite endpoints in clinical diabetes trials. Secondly, to compare the ratings of outcomes between patients with low and high education.

Methods

Using a pre-piloted questionnaire, patients with diabetes and doctors working with diabetes were asked to rate the importance of 36 different outcomes commonly used in trials assessing intervention effects in patients with diabetes. The respondents were asked to rate individual outcomes as being either critical, of major importance, of moderate importance, or of minor importance.

Results

The study population consisted of 139 patients with a mean age of 56.6 years and an average duration of diabetes for 13.6 years and 45 doctors with a mean time of practice of 19.6 years. There was no difference between patients' and doctors' rating of risk of mortality and non-fatal myocardial infarction, and percutaneous coronary intervention (all p-values > 0.34). Non-fatal stroke, admission for heart failure or angina was perceived more severely by patients compared to doctors (all p-values < 0.03). Patients rated risk of foot-ulcers, amputations and quality of life as more important compared to doctors (p-values < 0.01).

Conclusion

The current study suggest that patients and doctors weigh some diabetic outcomes used as part of composite endpoints in clinical diabetes trials differently. These findings call for more studies on patient reported outcomes and patient education for improved personal care.

Highlights

• We performed this study to assess how patients and practicing physicians rate the importance of outcomes commonly used in diabetes trials.• We found that patients and doctors rate the importance of some outcomes used in clinical diabetes trials differently.• These findings suggest that shared decision making is pivotal when taking clinical decisions and that future diabetes studies incorporate end points relevant to both patients and clinicians and do not combine end points which are not equally important.

Type 1 diabetes management and hospitalisation in the over 25's at an Australian outer urban diabetes clinic

AIMS

To describe clinic management and referral pathways among adults with type 1 diabetes (T1D) aged > 25 years attending a public outpatient diabetes service.

METHODS

Retrospective cohort study of people with T1D aged > 25 years seen by endocrinologists in one Australian urban public outpatient in 2017. Electronic and paper medical records were reviewed using a dataset adapted from the UK National Institute for Health and Care Excellence 2015 guidelines.

RESULTS

Among the 111 people with T1D (mean age 41 ± 13 years, 55% men, mean body mass index 27.1 ± 5.6 kg/m²), mean HbA1c was 8.1 ± 1.9% (66 ± 19 mmol/mol) (lower than the Australian National Diabetes Audit: 8.5%/69 mmol/mol) with 25.5% meeting the guideline target of < 53 mmol/mol (7.0%). Most people had seen a diabetes educator (80.2%) or dietitian (73.0%) and had complication screening. Complication rates were high (nephropathy 20.4%, retinopathy 27.4%, peripheral neuropathy 30.1%, ischaemic heart disease/acute infarction 10.5%). Overall, 27% of referrals occurred following an acute inpatient admission or emergency department presentation and 13% for management of diabetes in pregnancy.

CONCLUSIONS

A high proportion of people with T1D accessed public specialist care either during pregnancy or after a largely avoidable acute glycaemia-related hospital presentation. Subsequent care was in line with national specialist standards. This area has a "wait for acute event" rather than "complication prevention" model of care, associated with under-referral to the local multidisciplinary specialist service. Understanding how widespread this model of care is, and ways to reduce its prevalence, are urgently required.

Positive Effects of Extra-Virgin Olive Oil Supplementation and DietBra on Inflammation and Glycemic Profiles in Adults With Type 2 Diabetes and Class II/III Obesity: A Randomized Clinical Trial

Background

Evidence on the effects of dietary interventions on inflammatory markers in individuals with obesity and type 2 diabetes mellitus (T2DM) is scarce. Our study evaluated the effects of extra-virgin olive oil alone and in combination with a traditional Brazilian diet on inflammatory markers and glycemic profiles in adults with both T2DM and class II/III obesity.

Methods

Adults aged 18-64 years with T2DM and class II/III obesity were randomized into two intervention groups: 1) extra-virgin olive oil only and 2) extra-virgin olive oil + a traditional Brazilian diet (OliveOil+DietBra). Data on sociodemographic characteristics, lifestyle, anthropometry, biochemical markers and inflammatory markers were collected. The primary outcomes were glycemic parameters and inflammatory markers. The body mass index (BMI) and weight were the secondary outcomes.

Results

Forty individuals with T2DM and class II/III obesity were enrolled, and 34 (85%) completed the intervention course. The intake of olive oil was 37.88 ± 12.50 mL/day in the olive oil group and 37.71 ± 12.23 mL/day in the OliveOil+DietBra group, with no significant difference between groups (p = 0.484). Compared to the olive oil only group, the OliveOil+DietBra group had significantly lower levels of fasting insulin (p = 0.047) at the end of the intervention, whereas the other glycemic parameters were not altered. In the OliveOil+DietBra group, serum levels of inflammatory cytokines, IL-1α (p = 0.006) and adiponectin (p = 0.049) were lower and those of TNFα were higher (p = 0.037). There was a significant reduction in BMI and weight compared to the baseline values in the OliveOil+DietBra group (p = 0.015).

Conclusions

The intervention with OliveOil+DietBra effectively decreased the levels of fasting insulin, IL-1α and adiponectin, suggesting its beneficial role in improving the inflammatory profiles and fasting insulin levels in adults with class II/III obesity and T2DM.

Clinical Trial Registration

ClinicalTrials.gov, identifier: NCT02463435.

Hemorrhage in pheochromocytoma surgery: evaluation of preoperative risk factors

OBJECTIVE

Pheochromocytoma surgery carries a higher risk of hemorrhage. Our objective was to identify preoperative risk factors for hemorrhage during pheochromocytoma surgery.

METHODS

Patients who underwent surgery and with postoperative pathological confirmation were enrolled. A total of 251 patients from our center were included in the investigation, and 120 patients from the First Affiliated Hospital, Sun Yat-sen University were included as an external validation dataset. Family and medical history, demographics, hemodynamics, biochemical parameters, image data, anesthesia and operation records, postoperative outcomes were collected. Postoperative complications were graded by the Clavien-Dindo classification. Correlation between intraoperative hemorrhage volume and postoperative outcomes was assessed. The features associated with intraoperative hemorrhage were identified by linear regression. All features that were statistically significant in the multiple linear regression were then used to construct models and nomograms for predicting intraoperative hemorrhage. The constructed models were evaluated by Akaike Information Criterion. Finally, internal and external validations were carried out by tenfold cross-validation.

RESULTS

Intraoperative hemorrhage volume was positively correlated with the postoperative hospitalization time (R = 0.454, P < 0.001) and the Clavien-Dindo grades (R = 0.664, P < 0.001). Features associated with intraoperative hemorrhage were male gender (β = 0.533, OR = 1.722, P = 0.002), tumor diameter (β = 0.027, OR = 1.027, P < 0.001), preoperative CCB use (β = 0.318, OR = 1.308, P = 0.123) and open surgery (β = 1.175, OR = 3.234, P < 0.001). Validations showed reliable results (internal (R = 0.612, RMSE = 1.355, MAE = 1.111); external (R = 0.585, RMSE = 1.398, MAE = 0.964)).

CONCLUSION

More intraoperative hemorrhage is correlated with longer postoperative hospitalization time and more severe postoperative complications. Male gender, larger tumor, preoperative CCB use and open surgery are preoperative risk factors for hemorrhage in PCC surgery.

Variability, Mean, and Baseline Values of Metabolic Parameters in Predicting Risk of Type 2 Diabetes

CONTEXT

The effect of baseline (B) and alteration of metabolic parameters (MPs), including plasma glucose (PG) testing, insulin resistance surrogates, and lipid profile and their mutual interactions on the development of type 2 diabetes mellitus (T2DM), has not been investigated systematically.

OBJECTIVE

To access the association of the past variability (V), past mean (M), and B values of various MPs and their mutual interaction with the risk of T2DM.

METHODS

A community-based, longitudinal analysis was conducted using the Korean Genome and Epidemiology Study comprising 3829 nondiabetic participants with completed MPs measurements during 3 biannually visits who were followed over the next 10 years. Outcomes included the incidence of T2DM during follow-up.

RESULTS

Among predictors, PG concentrations measured during the oral glucose tolerance test were the most prominent T2DM determinants, in which the M of the average value of fasting PG (FPG), 1-hour, and 2-hour PGs had the strongest discriminative power (hazard ratios and 95% CI for an increment of SD: 3.00 (2.5-3.26), AUC: 0.82). The M values of MPs were superior to their B and V values in predicting T2DM, especially among postload PGs. Various mutual interactions between indices and among MPs were found. The most consistent interactants were the M values of high-density lipoprotein cholesterol and the M and V values of FPG. The findings were similar in normal glucose tolerance participants and were confirmed by sensitivity analyses.

CONCLUSION

Postload PG, past alteration of measurements, and mutual interactions among indices of MPs are important risk factors for T2DM development.

Effect of metformin on microvascular outcomes in patients with type 2 diabetes: A systematic review and meta-analysis

AIMS

Examine the efficacy of metformin compared to placebo or other glucose-lowering medications on microvascular outcomes in patients with Type 2 Diabetes Mellitus (T2DM).

METHODS

MEDLINE, EMBASE, Web of Science, and Scopus were searched from database inception to March 2020. We included randomized clinical trials of patients with T2DM receiving metformin compared with another active glucose-lowering treatment or placebo in which a microvascular outcome was assessed. The risk of bias was assessed using the Cochrane Risk of Bias tool. Microvascular complications included kidney-related outcomes, retinopathy, and peripheral neuropathy. An inverse-weighted variance random-effect meta-analysis was performed to estimate drugs effect over microvascular disease. PROSPERO (CRD42019120365).

RESULTS

Nineteen RCTs (n = 18,181) were included. Metformin increased estimated glomerular filtration rate (eGFR) by a mean difference (MD) of 1.08 (95% CI 0.84 to 1.33 ml/min/1.73 m²) after 24 weeks. No effect was found on urinary albumin-creatinine ratio, serum creatinine, and end-stage kidney disease; Patient-important outcomes regarding kidney disease, retinal outcomes, peripheral neuropathy or quality of life were not assessed by any of the included studies and could not be analyzed.

CONCLUSIONS

There is no evidence of clinically significant beneficial effect of metformin therapy as compared to other glucose-lowering medications or placebo on the examined microvascular complications.

Effective Overall Glycaemic Control with Fast-Acting Insulin Aspart Across Patients with Different Baseline Characteristics: A Post Hoc Analysis of the Onset 9 Trial

AIMS

To investigate the efficacy and safety of fast-acting insulin aspart (faster aspart) compared with insulin aspart (IAsp) in participants with type 2 diabetes (T2D) across different subgroups.

METHODS

We report on a post hoc analysis of onset 9, a 16-week trial of participants with T2D randomised to faster aspart (n = 546) or IAsp (n = 545). Participants were grouped by baseline HbA1c (< 7.0%, ≥ 7.0%), meal test bolus insulin dose (≤ 10 units [U], > 10 U to ≤ 20 U, > 20 U), body mass index (< 30 kg/m², ≥ 30 to < 35 kg/m², ≥ 35 kg/m²), and age (< 65 years, ≥ 65 years). Outcomes assessed were change from baseline in HbA1c and in 1-h postprandial glucose (PPG) increment, and severe or blood glucose (BG)-confirmed hypoglycaemia.

RESULTS

Faster aspart provided reductions in HbA1c comparable to IAsp across all subgroups, with improved 1-h PPG control compared with IAsp in several subgroups. Faster aspart had comparable or improved rates of severe or BG-confirmed hypoglycaemia versus IAsp, particularly in participants with good glycaemic control (HbA1c < 7.0%), the elderly (≥ 65 years old), and those with insulin resistance (> 20 U meal test bolus insulin dose).

CONCLUSIONS

Faster aspart provides effective overall glycaemic control, with improved early PPG control compared with IAsp across a range of patient characteristics.

CLINICAL TRIAL REGISTRATION

NCT03268005.

Good Clinical Practice of the Italian Society of Thalassemia and Haemoglobinopathies (SITE) for the Management of Endocrine Complications in Patients with Haemoglobinopathies

Background: The treatment of endocrinopathies in haemoglobinopathies is a continually expanding research area; therefore, recommendations supporting the appropriateness of treatments are a pressing need for the medical community. Methods: The Management Committee of SITE selected and gathered a multidisciplinary and multi-professional team, including experts in haemoglobinopathies and experts in endocrinopathies, who have been flanked by experts with methodological and organizational expertise, in order to formulate recommendations based on the available scientific evidence integrated by personal clinical experience. The project followed the systematic approach for the production of clinical practice guidelines according to the methodology suggested by the National Center for Clinical Excellence, Quality and Safety of Care (CNEC). Results: Out of 14 topics, 100 clinical questions were addressed, and 206 recommendations were elaborated on. The strength of recommendations, panel agreement, a short general description of the topic, and the interpretation of evidence were reported. Conclusions: Good Practice Recommendations are the final outcome of translational research and allow one to transfer to the daily clinical practice of endocrine complications in haemoglobinopathies.

The presence of diabetes impacts liver fibrosis and steatosis by transient elastography in a primary care population

INTRODUCTION AND OBJECTIVES

Noninvasive liver assessment in type 2 diabetes (T2DM) in a primary care population identifies higher risk non-alcoholic fatty liver disease (NAFLD). We aimed to evaluate the association of T2DM with liver fibrosis and steatosis by transient elastography (TE).

MATERIALS AND METHODS

This is a retrospective study of a TE referral program where primary care physicians were able to order TE. Patients with alcohol abuse were excluded. TE and Controlled Attenuation Parameter (CAP) scores were obtained. Multivariable linear and logistic regression models were used to adjust for confounders.

RESULTS

28% had T2DM. The mean TE score in T2DM patients was 8.3 (±6) kilopascal (kPa) and 6.4 (±3.7) kPa in those without T2DM (p = 0.0001). Those with T2DM had a higher CAP (322 ± 51 dB/m vs. 296 ± 57 dB/m, p < 0.0001). In multivariable analysis, T2DM was associated with TE score (β: 1.9, 95% confidence interval [CI]: 0.74-3.1, p = 0.001) and CAP (β: 2.8, 95% CI: 9.3-36.2, p = 0.001). Patients with T2DM had higher-risk TE scores and more steatosis by CAP.

CONCLUSION

T2DM is associated with liver fibrosis and steatosis by TE within a primary care population. A TE referral pathway may be utilized for T2DM patients who are at higher risk of NAFLD and its complications.

Association of Metformin with the Mortality and Incidence of Cardiovascular Events in Patients with Pre-existing Cardiovascular Diseases

INTRODUCTION

Whether metformin reduces all-cause cardiovascular mortality and the incidence of cardiovascular events in patients with pre-existing cardiovascular diseases (CVD) remains inconclusive. Some randomised controlled trials (RCTs) and cohort studies have shown that metformin is associated with an increased risk of mortality and cardiovascular events.

METHODS

We conducted a pooling synthesis to assess the effects of metformin in all-cause cardiovascular mortality and incidence of cardiovascular events in patients with CVD. Studies published up to October 2021 in PubMed or Embase with a registration in PROSPERO (CRD42020189905) were collected. Both RCT and cohort studies were included. Hazard ratios (HR) with 95% CI were pooled across various trials using the random-effects model.

RESULTS

This study enrolled 35 published studies (in 14 publications) for qualitative synthesis and identified 33 studies (published in 26 publications) for quantitative analysis. We analysed a total of 61,704 patients, among them 58,271 patients were used to calculate all-cause mortality while 12,814 patients were used to calculate cardiovascular mortality. Compared with non-metformin control, metformin usage is associated with a reduction in all-cause mortality (HR: 0.90; 95% CI 0.83, 0.98; p = 0.01), cardiovascular mortality (HR: 0.89; 95% CI 0.85, 0.94; p < 0.0001), incidence of coronary revascularisation (HR: 0.79; 95% CI 0.64, 0.98; p = 0.03), and heart failure (HR: 0.90; 95% CI 0.87, 0.94; p < 0.0001) in patients with pre-existing cardiovascular diseases.

CONCLUSION

Metformin use is associated with a reduction in all-cause mortality, cardiovascular mortality, incidence of coronary revascularisation, and heart failure in patients with CVD; however, metformin usage was not associated with reduction in the incidence of myocardial infarction, angina, or stroke.

Development and validation of the self-management Barriers and Supports Evaluation for working-aged adults with type 1 diabetes mellitus

INTRODUCTION

To optimize type 1 diabetes mellitus self-management, experts recommend a person-centered approach, in which care is tailored to meet people's needs and preferences. Existing tools for tailoring type 1 diabetes mellitus education and support are limited by narrow focus, lack of strong association with meaningful outcomes like A1c, or having been developed before widespread use of modern diabetes technology. To facilitate comprehensive, effective tailoring for today's working-aged adults with type 1 diabetes mellitus, we developed and validated the Barriers and Supports Evaluation (BASES).

RESEARCH DESIGN AND METHODS

Participants 25-64 years of age with type 1 diabetes mellitus were recruited from clinics and a population-based registry. Content analysis of semistructured interviews (n=33) yielded a pool of 136 items, further refined to 70 candidate items on a 5-point Likert scale through cognitive interviewing and piloting. To develop and validate the tool, factor analyses were applied to responses to candidate items (n=392). Additional survey data included demographics and the Diabetes-Specific Quality of Life (QOL) Scale-Revised. To evaluate concurrent validity, hemoglobin A1c (HbA1c) values and QOL scores were regressed on domain scores.

RESULTS

Factor analyses yielded 5 domains encompassing 30 items: Learning Opportunities, Costs and Insurance, Family and Friends, Coping and Behavioral Skills, and Diabetes Provider Interactions. Models exhibited good to adequate fit (Comparative Fit Index >0.88 and Root Mean Squared Error of Approximation <0.06). All domains demonstrated significant associations with HbA1c and QOL in the expected direction, except Family and Friends. Coping and Behavioral Skills had the strongest associations with both HbA1c and QOL.

CONCLUSIONS

The BASES is a valid, comprehensive, person-centered tool that can tailor diabetes support and education to individuals' needs in a modern practice environment, improving effectiveness and uptake of services. Clinicians could use the tool to uncover patient-specific barriers that limit success in achieving HbA1c goals and optimal QOL.

Effect of the Chinese New Year Public Holiday on the Glycemic Control of T1DM With Intensive Insulin Therapy

AIMS

There is limited evidence that evaluates the glycemic control of type 1 diabetes mellitus (T1DM) during the Chinese New Year public holiday in China. The Chinese New Year public holiday represents various challenges to glycemic control, especially in T1DM patients, in China. We aimed to assess the effect of the Chinese New Year public holiday on several glucose metrics using flash glucose monitoring (FGM) in patients with T1DM.

METHODS

Complete FGM data for 1 week before, 1 week during and 1 week after the Chinese New Year public holiday were available for 71 T1DM patients treated with multiple daily insulin injection (MDI) therapy (n = 51) or continuous subcutaneous insulin infusion (CSII) treatment (n = 20). The mean age of the study participants was 13 (9, 30) years. Of note, 59.2% of the patients (n = 42) were adults, and 40.8% of the patients (n = 29) were minors. The interval between each two adjacent periods was one week. The indicators of mean glucose, glucose variability and time in different glycemic ranges were analyzed.

RESULTS

The Chinese New Year public holiday was associated with an increase in mean blood glucose (8.4 ± 1.7 vs. 9.2 ± 2.5; P < 0.001) and time above range (TAR) (27.9% ± 16.6% vs. 35.0% ± 22.3%; P< 0.001) but a decrease in time in range (TIR) (65.1% ± 15.5% vs. 58.0% ± 19.0%; P < 0.001) and coefficient of variation (CV) (65.1% ± 15.5% vs. 58.0% ± 19.0%; P < 0.001). There was no significant difference in time below range (TBR). The glycemic control deteriorated during the Chinese New Year public holiday in our study population regardless of age. Interestingly, in the CSII group, none of the metrics of glucose control significantly changed during the Chinese New Year public holiday.

CONCLUSIONS

These results suggested that less self-management may worsen glycemic control in the short term, indicating a need for more refined management algorithms during the Chinese New Year public holiday for T1DM patients.

Relations of physical signs to genotype, lipid and inflammatory markers, coronary stenosis or calcification, and outcomes in patients with heterozygous familial hypercholesterolemia

BACKGROUND

Although the presence of physical signs [tendon xanthomas and/or corneal arcus (TX/CA)], are associated with the risk of coronary artery disease in patients with heterozygous familial hypercholesterolemia (HeFH), their relationship with genotypes and clinical characteristics has not been fully determined. This study aimed to examine the association of TX/CA with genetic mutation, lipid- and inflammation-related markers, the severity of coronary stenosis or calcification, and cardiovascular events (CVEs) in patients with HeFH.

METHODS

LDLR, APOB, and PCSK9 genes were screened in 523 HeFH patients, and patients with TX/CA (n = 50) were 1:4 propensity score-matched to patients without TX/CA (n = 200) to adjust for age and sex. Laboratory markers (proprotein convertase subtilisin/kexin type 9 [PCSK9], lipoprotein(a) and high-sensitivity C-reactive protein [hsCRP]), computed tomography angiography, coronary angiography, and follow-up for CVEs were performed.

RESULTS

Patients with physical signs had significantly higher low-density lipoprotein cholesterol levels; higher PCSK9 or hsCRP concentrations; more LDLR positive mutations; and higher prevalence of high tertiles of Gensini, SYNTAX and Jeopardy scores as well as coronary artery calcium scores than did those without. Over an average follow-up of 3.7 years, the incidence of CVEs was significantly higher in patients with TX/CA (log-rank p < 0.001). Patients with physical signs and mutation positivity had threefold higher risks of CVEs (adjusted hazard ratio 3.34, 95% confidence interval 1.04-10.72, p = 0.024).

CONCLUSIONS

Physical signs were associated with genotypes and phenotypes, and worse outcomes in patients with HeFH, suggesting that these signs may help in risk stratification in these patients.

Effectiveness of Game-Based Self-Management Interventions for Individuals with Diabetes: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Objective: Self-management is essential for individuals with diabetes. However, traditional self-management interventions may be hard to follow for other patients. Although games can stimulate extrinsic motivations, its application on self-management remains unclear. This review aims to evaluate the effects of game-based self-management interventions on health outcomes. Materials and Methods: We utilize PubMed, CINAHL, Cochrane Central, EMBASE, ProQuest Dissertation and Theses, PsycINFO, and Scopus from their inception until January 20, 2020. Meta-analyses are performed using Comprehensive Meta-analysis 3.0 software. The overall effect is measured using Hedges' g and determined using Z-statistics at significance level of P < 0.05. Heterogeneity is assessed using χ² and I² statistics. The risk of bias tool and the grades of recommendation, assessment, development, and evaluation system are used to assess individual and overall quality of evidence, respectively. Results: A total of 2150 records are identified, and 13 randomized controlled trials are selected. Meta-analyses revealed that game-based self-management interventions significantly improved patients' change in glycated hemoglobin (HbA1c) level (g = 0.18, P = 0.02), adherence to physical activities (g = 0.59, P < 0.001), balance (g = 0.94-1.14, P < 0.001), and fall efficacy (g = 1.01, P < 0.001). Significant results were only found for the three-trial meta-analysis for HbA1c changes, but not for the two other HbA1c meta-analyses that included more trials. Furthermore, negligible improvements were observed in glycated hemoglobin at postintervention and follow-up assessments, diabetes knowledge, and self-efficacy. Conclusion: Game-based self-management can consider a supplementary intervention. Overall evidence is ranging from very low to low. Future studies can consider a large sample size with high-quality design according to the Consolidated Standards of Reporting Trials statement criteria.

Impact of New York State's Health Home program on access to care among patients with diabetes

INTRODUCTION

Access to care is essential for patients with diabetes to maintain health and prevent complications, and is important for health equity. New York State's Health Homes (HHs) provide care management services to Medicaid-insured patients with chronic conditions, including diabetes, and aim to improve quality of care and outcomes. There is inconsistent evidence on the impact of HHs, and care management programs more broadly, on access to care.

RESEARCH DESIGN AND METHODS

Using a cohort of patients with diabetes derived from electronic health records from the INSIGHT Clinical Research Network, we analyzed Medicaid data for HH enrollees and a matched comparison group of HH non-enrollees. We estimated HH impacts on several access measures using natural experiment methods.

RESULTS

We identified and matched 11 646 HH enrollees; patients were largely non-Hispanic Black (29.9%) and Hispanic (48.7%), and had high rates of dual eligibility (33.0%), Supplemental Security Income disability enrollment (49.1%), and multiple comorbidities. In the 12 months following HH enrollment, HH enrollees had one more month of Medicaid coverage (p<0.001) and 4.6 more outpatient visits than expected (p<0.001, evenly distributed between primary and specialty care). There were also positive impacts on the proportions of patients with follow-up visits within 7 days (4 percentage points (pp), p<0.001) and 30 days (6pp, p<0.001) after inpatient care, and on the proportion of patients with follow-up visits within 30 days after emergency department (ED) care (4pp, p<0.001). We did not find meaningful differences in continuity of care. We found small positive impacts on the proportion of patients with an inpatient visit and the proportion with an ED visit.

CONCLUSIONS

New York State's HH program improved access to care for Medicaid recipients with diabetes. These findings have implications for New York State Medicaid as well as other providers and care management programs.

Leveraging advances in diabetes technologies in primary care: a narrative review

Primary care providers (PCPs) play an important role in providing medical care for patients with type 2 diabetes. Advancements in diabetes technologies can assist PCPs in providing personalised care that addresses each patient's individual needs. Diabetes technologies fall into two major categories: devices for glycaemic self-monitoring and insulin delivery systems. Monitoring technologies encompass self-measured blood glucose (SMBG), where blood glucose is intermittently measured by a finger prick blood sample, and continuous glucose monitoring (CGM) devices, which use an interstitial sensor and are capable of giving real-time information. Studies show people using real-time CGM have better glucose control compared to SMBG. CGM allows for new parameters including time in range (the time spent within the desired target glucose range), which is an increasingly relevant real-time metric of glycaemic control. Insulin pens have increased the ease of administration of insulin and connected pens that can calculate and capture data on dosing are becoming available. There are a number of websites, software programs, and applications that can help PCPs and patients to integrate diabetes technology into their diabetes management schedules. In this article, we summarise these technologies and provide practical information to inform PCPs about utility in their clinical practice. The guiding principle is that use of technology should be individualised based on a patient's needs, desires, and availability of devices. Diabetes technology can help patients improve their clinical outcomes and achieve the quality of life they desire by decreasing disease burden.KEY MESSAGESIt is important to understand the role that diabetes technologies can play in primary care to help deliver high-quality care, taking into account patient and community resources. Diabetes technologies fall into two major categories: devices for glycaemic self-monitoring and insulin delivery systems. Modern self-measured blood glucose devices are simple to use and can help guide decision making for self-management plans to improve clinical outcomes, but cannot provide "live" data and may under- or overestimate blood glucose; patients' monitoring technique and compliance should be reviewed regularly. Importantly, before a patient is provided with monitoring technology, they must receive suitably structured education in its use and interpretation.Continuous glucose monitoring (CGM) is now standard of care for people with type 1 diabetes and people with type 2 diabetes on meal-time (prandial) insulin. Real-time CGM can tell both the patient and the healthcare provider when glucose is in the normal range, and when they are experiencing hyper- or hypoglycaemia. Using CGM data, changes in lifestyle, eating habits, and medications, including insulin, can help the patient to stay in a normal glycaemic range (70-180 mg/dL). Real-time CGM allows for creation of an ambulatory glucose profile and monitoring of time in range (the time spent within target blood glucose of 70-180 mg/dL), which ideally should be at least 70%; avoiding time above range (>180 mg/dL) is associated with reduced diabetes complications and avoiding time below range (<70 mg/dL) will prevent hypoglycaemia. Insulin pens are simpler to use than syringes, and connected pens capture information on insulin dose and injection timing.There are a number of websites, software programs and applications that can help primary care providers and patients to integrate diabetes technology into their diabetes management schedules. The guiding principle is that use of technology should be individualised based on a patient's needs, desires, skill level, and availability of devices.