American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan

Investigating the Association Between Family Socioeconomic Profile and Diabetes Control in Children: A Cross-Sectional Study From Sudan

AIMS

Diabetes mellitus is the most common endocrine disease in childhood which significantly impacts quality of life, morbidity and mortality. This study aimed to investigate the socioeconomic background of children with diabetes and their families and to assess its association with diabetes control.

METHODS

This cross-sectional study was conducted in Khartoum State, Sudan, in 2018, at three outpatient diabetes clinics, using standardised questionnaires. We included 138 diabetic children (T1D and T2D) aged 2-18 years using systematic random sampling. Descriptive statistics, economic indicator and inferential statistics were applied using SPSS version 20. An HbA1C level of > 7.0% was set as the cut-point for uncontrolled diabetes. A p-value of < 0.05 was considered statistically significant.

RESULTS

The mean age of the children was 11.1 (3.64) years. Over half of the respondents were not covered by any insurance scheme and 73% lived in urban areas. Mothers had a mean age of 37.3 (7.8), with one-fourth being illiterate, while fathers had a mean age of 45.4 (9.3). Twenty per cent of parents had higher education. Two-thirds of the participants had their HbA1C levels checked within the last 3 months. The prevalence of uncontrolled diabetes was 78.0%. No statistically significant association was found between HbA1C levels and families' socioeconomic, demographic or clinical characteristics (p > 0.05).

CONCLUSION

Neither children' nor parents' characteristics influenced HbA1C level. The high rate of uncontrolled diabetes (78.0%), and other countries showing better profiles of control, suggests the need for exploring other contributing factors. Insulin availability and lack of home glucose monitoring need to be considered. We recommend future prospective studies to consider these factors and use multiple HbA1C measures' average as a better indicator of diabetic control.

Association of Baseline Thyroid Stimulating Hormone With In-Hospital Outcomes in Patients With Atrial Fibrillation and Coronary Artery Diseases

OBJECTIVE

Thyroid stimulating hormone (TSH) is related to increased atrial fibrillation (AF) inducibility and plays an important role in a variety of cardiovascular diseases. However, the association of baseline TSH with in-hospital outcomes in patients with AF and coronary artery disease (CAD) is unknown. This study aimed to investigate the distribution of baseline TSH and its association with in-hospital outcomes (major adverse cardiovascular events, all-cause death, or heart failure [HF]) in AF patients combined with CAD.

METHODS

A total of 19 725 patients with AF were included. The status of blood TSH was investigated. Patients with AF and CAD were divided into low, median, and high-TSH subgroups based on tertiles of baseline TSH levels. Clinical characteristics and in-hospital outcomes were compared. Logistic regression analysis was performed to determine the association of TSH with in-hospital outcomes. Subgroup analysis was also performed.

RESULTS

In patients with AF and CAD, compared with the low-TSH group, the median-TSH (OR 0.277, 95% CI 0.078-0.991, P = .048) and high-TSH (OR 0.163, 95% CI 0.036-0.750, P = .020) groups were associated with decreased all-cause death. Besides, high TSH showed a protective role for HF events, and the same results were seen in females, age ≥75, and non-non-hypertension subgroups.

CONCLUSION

Higher baseline TSH presented a protective effect on in-hospital all-cause death and HF in patients with AF combined with CAD.

Antihypertensive medication prescription dispensation among pregnant women in the United States: A cohort study

IMPORTANCE

Hypertension is increasingly common in pregnancy capable individuals, yet there is limited data on antihypertensive medication dispensation in peripartum individuals.

OBJECTIVE

To describe antihypertensive medication dispensation from preconception through the first year postpartum.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Truven Health Market Scan administrative data from 2008 to 2014 to identify women in the United States with commercial or government health insurance, aged 15-54, free from heart disease, who experienced a pregnancy and filled at least 1 prescription for an antihypertensive medication between 3 months prior to conception and 12 months after the end of the pregnancy.

MAIN OUTCOMES AND MEASURES

We describe antihypertensive dispensation patterns (continuation, initiation, and discontinuation) by medication class during 5 time periods: preconception, first, second, and third trimesters, and the first year postpartum.

RESULTS

Of 1,058,521 pregnancies, 108,614 (10.3%) were exposed to at least 1 antihypertensive medication dispensation. The most commonly dispensed medications across all periods combined were adrenergic blockers, calcium channel blockers (CCBs), and diuretics. Renin-angiotensin-aldosterone system (RAAS) inhibitors were the third most dispensed medication class in the preconception period (26.4%), and fills decreased to 5.7% and 1.7% in the second and third trimesters, respectively. Of the women with chronic hypertension who filled at least 1 prescription prior to conception, 8.4% were not dispensed an antihypertensive medication during the first year after delivery.

CONCLUSIONS AND RELEVANCE

Antihypertensive prescription dispensation of both preferred and potentially harmful agents is common in pregnancy capable individuals. Patterns of dispensation suggest room for improvement in the treatment of chronic hypertension after a pregnancy.

Determinants and Characteristics of Insulin Dose Requirements in Children and Adolescents with New-Onset Type 1 Diabetes: Insights from the INSENODIAB Study

Aims

New-onset type 1 diabetes mellitus (T1D) in pediatric patients represents a clinical challenge for initial total daily insulin dosing (TIDD) due to substantial heterogeneity in practice and lack of consensus on the optimal starting dose. Our INSENODIAB (INsulin SEnsitivity in New Onset type 1 DIABetes) study is aimed at (1) exploring the influence of patient-specific characteristics on insulin requirements in pediatric patients with new-onset T1D; (2) constructing a predictive model for the recommended TIDD tailored to individual patient profiles; and (3) assessing potential associations between TIDD and patient outcomes at follow-up intervals of 3 and 12 months.

Methods

We conducted a comprehensive analysis of medical records for children aged 6 months to 18 years, hospitalized for new-onset T1D from 2013 to 2022. The study initially involved multivariable regression analysis on a retrospective cohort (rINSENODIAB), incorporating baseline variables. Subsequently, we validated the model robustness on a prospective cohort (pINSENODIAB) with a significance threshold of 5%. The model accuracy was assessed by Pearson's correlation.

Results

Our study encompassed 103 patients in the retrospective cohort and 80 in the prospective cohort, with median TIDD at diagnosis of 1.1 IU/kg BW/day (IQR 0.5). The predictive model for optimal TIDD was established using baseline characteristics, resulting in the following formula: TIDD (IU/d) = ([0.09 × Age2] + [0.68 × %Weight Loss] + [28.60 × Veinous pH] - [1.03 × Veinous bicarbonates] + [0.81 × Weight] - 194.63). Validation of the model using the pINSENODIAB cohort demonstrated a significant Pearson correlation coefficient of 0.74. Notably, no significant correlation was observed between TIDD at diagnosis and partial remission markers (IDAA1C, C-peptide) at 3- and 12-months postdiagnosis time points.

Conclusions

In the context of new-onset T1D in pediatric patients, we identified key influencing factors for determining optimal TIDD, including age, percentage of weight loss, weight, veinous pH, and bicarbonates. These findings have paved the way for the development of a dosing algorithm to potentially expedite glycemic control stabilization and facilitate a more individualized approach to treatment regimens.

A nomogram model for predicting malnutrition among older hospitalized patients with type 2 diabetes: a cross-sectional study in China

BACKGROUND

Malnutrition remains a pervasive issue among older adults, a prevalence that is markedly higher among those diagnosed with diabetes. The primary objective of this study was to develop and validate a risk prediction model that can accurately identify instances of malnutrition among elderly hospitalized patients with type 2 diabetes mellitus (T2DM) within a Chinese demographic.

METHODS

This cross-sectional study was conducted between August 2021 and August 2022, we enrolled T2DM patients aged 65 years and above from endocrinology wards. The creation of a nomogram for predicting malnutrition was based on risk factors identified through univariate and multivariate logistic regression analyses. The predictive accuracy of the model was evaluated by the receiver operating characteristic curve (ROC),the area under the ROC (AUC), the concordance index (C-index), and calibration curves.

RESULTS

The study included a total of 248 older T2DM patients, with a recorded malnutrition prevalence of 26.21%. The identified critical risk factors for malnutrition in this cohort were body mass index, albumin, impairment in activities of daily living, dietary habits, and glycosylated hemoglobin. The AUC of the nomogram model reached 0.914 (95% CI: 0.877-0.951), with an optimal cutoff value of 0.392. The model demonstrated a sensitivity of 80.0% and a specificity of 88.5%. Bootstrap-based internal verification results revealed a C-index of 0.891, while the calibration curves indicated a strong correlation between the actual and predicted malnutrition risks.

CONCLUSIONS

This study underscores the critical need for early detection of malnutrition in older T2DM patients. The constructed nomogram represents a practical and reliable tool for the rapid identification of malnutrition among this vulnerable population.

Adoption of IWGDF guidance on prevention and management of foot problems in diabetes for local use in Iran by ADAPTE methodology: a step toward best practice

Purpose

Adoption of international working group on the diabetic foot (IWGDF) guidance on prevention and management of foot problems in patients with diabetes was the study aim.

Methods

The ADAPTE process consisted of three main phases of set-up, adoption, and finalization with overall 24 steps was used. In set- up phase, organizing committee by a multidisciplinary approach was established. In adoption phase, comprehensive search in databases and guideline resources was done. According to the inclusion criteria, the 2015IWGDF guidance was selected for adoption process. Quality, currency, content and consistency of the guidance were assessed. Also, consensus on different level of agreement for each recommendation were reported. On finalization phase, the adopted version was reviewed by the guidance developer and the final guidance for local use in Iran was disseminated.

Results

The 2015 IWGDF guidance with 77 recommendations was adopted after screening of 1760 documents retrieved from Jan. 2006 to Nov. 2016. An organizing committee was established according to a multidisciplinary approach including 73 members with endocrinology, orthopedic & vascular surgery, dermatology, infectious diseases, physical medicine and rehabilitation specialties, general practitioners and nurses. This guidance obtained a good quality in all six domains of AGREE II instrument (Score ≥ 80%), good currency, content, and consistency. Also, during the third round of Delphi, the consensus on the agreement level of each recommendation were greater than 80% and 77 recommendations of the original guidance were kept in the adopted version.

Conclusion

The 2015 IWGDF guidance with 77 recommendations adopted for local use in different health care settings of Iran.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01121-0.

Individualized Glycemic Control in Type 2 Diabetic Patients in Iran: A Multi-Center Data Analysis

Background

Clinical guidelines and expert committees have recently suggested that the hemoglobin A1C (HbA1c) should be individualized based on various criteria. Data regarding the achievement of individualized glycemic targets in type 2 diabetes mellitus (T2DM) patients is scant in Iran. We intended to provide information found on real-world outcomes from the perspective of an individualized recommendation.

Methods

A cross-sectional analysis was conducted in 15 diabetes centers in Iran between 2013-2017. Two steps cluster sampling selection was used to recruit 1591 patients with T2DM. Considering Ismail-Beigi's individualized strategy, the study population was categorized into five treatment intensities of HbA1c: most intensive (≤6.5%), intensive (6.5-7.0%), less intensive (~7.0%), not intensive (7.0-8.0%), and moderated (~8.0%). The percentage of patients who met their group individualized glycemic targets was estimated as the degree of achievement of each treatment intensity.

Results

The cumulative incidence rate of early microvascular, advanced microvascular, and macrovascular complications was 53%, 25%, and 34%, respectively. Besides, [78% 77.6-79%] of patients did not achieve individualized glycemic targets.

Conclusion

The outcome showed poor individualized glycemic control and a high incidence of diabetes complications. Considering individualized HbA1c targets for Iranian patients with T2DM is an urgent need.

Nutritional Recommendations for Type 2 Diabetes: An International Review of 15 Guidelines

OBJECTIVES

Recommendations from clinical practice guidelines (CPGs) for individuals with type 2 diabetes mellitus (T2DM) may be inconsistent, and little is known about their quality. Our aim in this study was to systematically review the consistency of globally available CPGs containing nutritional recommendations for T2DM and to assess the quality of their methodology and reporting.

METHODS

PubMed, China Biology Medicine and 4 main guideline websites were searched. Four researchers independently assessed quality of the methodology and reporting using the Appraisal of Guidelines for Research and Evaluation, second edition (AGREE II) instrument and the Reporting Items for Practice Guidelines in HealThcare (RIGHT) checklist.

RESULTS

Fifteen CPGs include 65 nutritional recommendations with 6 sections: 1) body weight and energy balance; 2) dietary eating patterns; 3) macronutrients; 4) micronutrients and supplements; 5) alcohol; and 6) specific, functional foods. Current nutritional recommendations for individuals with T2DM on specific elements and amounts are not completely consistent in different CPGs and fail to assign the specific supporting evidence and strength of recommendations. To use nutritional recommendations to guide and manage individuals with T2DM, it is important to address the current challenges by establishing a solid evidence base and indicating the strength of recommendations. Overall, 8 CPGs classified as recommended for clinical practice used AGREE II. Fifteen CPGs adhere to <60% of RIGHT checklist items.

CONCLUSIONS

High-quality evidence is needed to potentially close knowledge gaps and strengthen the recommendation. The AGREE II instrument, along with the RIGHT checklist, should be endorsed and used by CPG developers to ensure higher quality and adequate use of their products.

Associations of pre-hospital statin treatment with in-hospital outcomes and severity of coronary artery disease in patients with first acute coronary syndrome-findings from the CCC-ACS project

Background

The current burden of dyslipidemia, the pre-hospital application of statins and the association of pre-hospital statins with the severity of coronary artery disease (CAD) and in-hospital outcomes in Chinese patients with first acute coronary syndrome (ACS) are very significant and remain unclear.

Methods

A total of 41,183 patients who underwent coronary angiography and were diagnosed with ACS for the first time from a nationwide registry study (CCC-ACS) were enrolled. The severity of CAD was assessed using the CAD prognostic index (CADPI). The patients were classified into statin and non-statin groups according to their pre-hospital statin treatment status. Clinical characteristics, CADPI and in-hospital outcomes were compared, and a logistic regression analysis was performed to determine whether pre-hospital statin therapy is associated with in-hospital outcomes and CADPI. A sensitivity analysis was used to further explore the issues above.

Results

The non-statin group had more in-hospital all-cause deaths (1.2 vs. 0.8%, P = 0.010). However, no association exists between statin pretreatment and in-hospital major adverse cardiovascular events (MACEs) or all-cause deaths in the entire population and subgroups (all P > 0.05). Surprisingly, statin pretreatment was associated with an 8.9% higher risk of severely obstructive CAD (CADPI ≥ 37) (OR, 1.089; 95% CI, 1.010-1.175, P = 0.028), and similar results were observed in subgroups of females, those aged 50 to 75 years, and patients with hypertension.

Conclusion

Statin pretreatment was not related to MACEs or all-cause death during hospital stay, but it was associated with a higher risk of increased angiographic severity in patients with first ACS.

Evolution of Guideline Recommendations on Insulin Therapy in Type 2 Diabetes Mellitus Over the Last Two Decades: A Narrative Review

The prevalence of type 2 diabetes mellitus has been increasing worldwide. As the therapeutic options for type 2 diabetes mellitus have evolved over the last 2 decades, national and global guidelines related to type 2 diabetes mellitus pharmacotherapy issued by various organizations have tended to vary in their recommendations. This narrative review aimed to analyze the key recommendations by major global and national guidelines on the initiation of insulin therapy in patients with type 2 diabetes mellitus over the last 20 years. Strategies for insulin therapy for titration and intensification were also assessed. All guidelines recommend initiation of insulin (basal/ premixed/other formulations) when glycemic targets are not achieved despite lifestyle measures and oral antidiabetic drugs. In the recent decade, early initiation of insulin has been recommended when the glycated hemoglobin levels are >10% or blood glucose levels are ≥300 mg/dL (16.7 mmol/L). Initiation is recommended at a dose of 10 units or 0.1-0.2 U/kg. Titration is advised to achieve the optimal dosage, while intensification is recommended when glycemic targets are not achieved despite titrating to an acceptable level. Glucose monitoring at periodic intervals is recommended for adequate glycemic control. The guidelines further suggest that the choice of insulin should be individualized, considering the clinical status of patients with type 2 diabetes mellitus. The physicians as well as patients should be a part of the decisions made regarding the therapeutic choice of regimen, preparation, and delivery device.

Hypoglycemic events and glycemic control effects between NPH and premixed insulin in patients with type 2 diabetes mellitus: A real-world experience at a comprehensive specialized hospital in Ethiopia

BACKGROUND

Though initiation of insulin results in a significant change in glycemic levels, treating patients without significant hypoglycemic events remains difficult in diabetes patients initiated with different insulin-based regimens. This study assessed the association of hypoglycemic incidence and glycemic control between NPH and premixed insulin regimens in patients with type 2 diabetes mellitus (T2DM).

METHODS

This was a retrospective observational study in patients with T2DM who were treated with insulin-based therapy from 2015 to 2020 at the University of Gondar Comprehensive Specialized hospital. Average fasting blood glucose (FBG) between NPH and premixed insulin regimens was compared using an independent t-test. The Association of NPH and premixed insulin regimens with hypoglycemic incidences and glycemic control was examined by a logistic regression model. P < 0.05 was statistically significant.

RESULTS

From 405 participants, more than half (55.3%) were males with a mean age of 59.2(±9.1) years. Baseline mean HbA1C and FBG levels were 12.73(±1.1) % and 347.7(±48.5) mg/dl, respectively. Within a one-year follow-up period of insulin initiation, the rate of hypoglycemia was 13.1%. The incidence of hypoglycemia was significantly higher in patients initiated with premixed insulin compared with NPH insulin regimens (P < 0.001). After one year of insulin initiation, HbA1C decreased from 12.7 to 7.6 and from 12.8 to 7.3% and FBG levels decreased from 347.5 to 160.7 and from 348.2 to 147.3 mg/dl following initiation of NPH and premixed insulin, respectively. Patients treated with premixed-based insulin were found more likely to achieve target FBG compared with patients treated with NPH insulin regimens after one year of initiation (P = 0.02).

CONCLUSION

Premixed insulin-based regimen has found to have a higher hypoglycemic incidence, but a better level of glycemic control compared to NPH insulin-based therapy. Therefore, patients initiated with premixed insulin need to be highly vigilant and motivated to recognize the symptoms of hypoglycemia.

Dapagliflozin, metformin, monotherapy or both in patients with metabolic syndrome

The present study evaluated the effects of dapagliflozin, a SGLT2 inhibitor, or dapagliflozin plus metformin versus metformin monotherapy in patients with metabolic syndrome. This study included patients who admitted in Jiangxi Provincial People’s Hospital from January 1, 2017 to December 31, 2019 and were diagnosed with metabolic syndrome. A total of 248 participants were randomly assigned to divide into three groups: dapagliflozin group; metformin group; dapagliflozin in combined with metformin group. Dapagliflozin group and metformin group were associated with similar improvements in components of metabolic syndrome. Relative to dapagliflozin or metformin monotherapy, dapagliflozin combined with metformin provided greater improvements in components of metabolic syndrome. So did HOMA-IR scores, fasting plasma insulin and inflammatory indicators (hsCRP, PMN/HDL-C and Monocytes/HDL-C). Dapagliflozin improved all components of metabolic syndrome in patients with metabolic syndrome. Furthermore, dapagliflozin combined with metformin showed more meaningful improvements in any of components of metabolic syndrome than dapagliflozin or metformin monotherapy.

The Usefulness of C-Reactive Protein to Albumin Ratio in the Prediction of Adverse Cardiovascular Events in Coronary Chronic Total Occlusion Undergoing Percutaneous Coronary Intervention

Inflammation and nutrition as main factors can affect the prognosis of patients with chronic total coronary occlusion (CTO) undergoing percutaneous coronary intervention (PCI). The C-reactive protein to albumin ratio (CAR) can clarify the inflammation and nutrition status, which are highly related to clinical outcomes. This study aims to investigate the association between CAR and adverse cardiovascular events in patients with CTO undergoing PCI. For this study, 664 patients were divided into three groups based on the tertiles of CAR. The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiovascular events (MACE). Over a median follow-up of 33.7 months, the primary endpoint occurred in 64 patients (9.6%) and the secondary endpoint occurred in 170 patients (25.6%). The patients with higher CAR represented a worse prognosis with all-cause death and cardiovascular death after the adjustment for the baseline risk factors. Adding the CAR values raised the predictive value for the incidence of the all-cause death and cardiovascular death but not MACE. The capacity of prognosis prediction was improved after the addition of the CAR value to the traditional prediction model.

Diabetes Control During Massachusetts Insurance Reform

Racial/ethnic disparities in glycemic control-a key diabetes outcome measure-continue to widen, even though the overall prevalence of glycemic control in the US has improved. Health insurance coverage may be associated with improved glycemic control, but few studies examine effects during a period of policy change. We assessed changes in glycemic control by racial/ethnic groups following the Massachusetts Health Insurance Reform for patients at two urban safety-net academic health systems between January 2005 and December 2013. We analyzed outcomes for three measures of poor glycemic control: 1) lack of a hemoglobin A1C (A1C) measure during a 6-month period; 2) A1C >8%; 3) A1C >9% before, during, and after implementation of insurance reform. We did not find increased rates of A1C monitoring or control following insurance reform overall or for specific racial/ethnic groups. We found evidence of worsened, not improved, glycemic control in some racial/ethnic groups in the post-reform period. The expansion of affordable insurance coverage was not associated with improved glycemic control in vulnerable populations.

Prognostic value of malnutrition using geriatric nutritional risk index in patients with coronary chronic total occlusion after percutaneous coronary intervention

BACKGROUND

Malnutrition is associated with poor prognosis in a wide range of chronic illnesses, however, the impact of malnutrition on long-term outcomes of patients at advanced stages of atherosclerosis, coronary chronic artery occlusion (CTO), is not known.

AIMS

This study aims to investigate the relationship between malnutrition and adverse cardiovascular events in patients with CTO after percutaneous coronary intervention (PCI).

METHODS

Baseline malnutrition risk was determined in 669 patients with CTO after PCI in this study. All patients were divided into 3 groups according to 3 categories of the geriatric nutritional risk index (GNRI): moderate to severe, GNRI of <92 (n = 70); low, GNRI of 92-98 (n = 197); and absence of risk, GNRI of ≥98 (n = 402). The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiovascular events (MACE).

RESULTS

Average age in this study was 65.32 ± 9.97 years old. More than one-third of patients were at risk of malnutrition (moderate to severe: 10.5%; low: 29.4%; and absence of risk: 60.1%). Over a median follow-up of 33 months, compared to those with absent risk for malnutrition, moderate to severe risk was associated with significantly increased risk for the all-cause death, cardiovascular death and MACE (hazard ratio [HR]: 2.90, 95% confidence interval [CI]: 1.43 to 5.87, P for trend = 0.002; HR: 3.72, 95% CI: 1.42 to 9.77, P for trend = 0.010; HR: 1.76, 95% CI: 1.02 to 3.03, P for trend = 0.040; respectively) after adjustment for baseline variables. Moreover, addition of the GNRI score significantly raised the predictive value for the all-cause death (0.383, p = 0.004 and 0.022, p = 0.011, NRI and IDI respectively), cardiovascular death (0.488, p < 0.001 and 0.013, p = 0.014, NRI and IDI respectively) and MACE (0.368, p = 0.004 and 0.014, p = 0.008, NRI and IDI respectively) as compared to traditional factors.

CONCLUSIONS

Malnutrition assessed by the GNRI score on admission was an independent predictor for adverse cardiovascular events in CTO patients after PCI. Addition of the GNRI score to the existing risk prediction model significantly increased the predictive ability for cardiovascular events in CTO patients after PCI.

Prognostic Value of Admission Mean Corpuscular Volume for Major Adverse Cardiovascular Events following Stent Implantation in Nondiabetic and Diabetic Patients with Acute Coronary Syndrome

Background

One of the key concerns of the clinician is to identify and manage risk factors for major adverse cardiovascular events (MACEs) in nondiabetic and diabetic patients with acute coronary syndrome (ACS) undergoing stent implantation. Mean corpuscular volume (MCV) is a marker of erythrocyte size and activity and is associated with prognosis of cardiovascular disease. However, the role of admission MCV in predicting MACEs following stent implantation in diabetes mellitus (DM), non-DM, or whole patients with ACS remains largely unknown.

Methods and Results

A total of 437 ACS patients undergoing stent implantation, including 294 non-DM (59.08 ± 10.24 years) and 143 DM (63.02 ± 9.92 years), were analyzed. Admission MCV was higher in non-DM than DM patients. During a median of 31.93 months follow-up, Kaplan-Meier curve demonstrated that higher admission MCV level was significantly associated with increased MACEs in whole and non-DM, but not in DM patients. In Cox regression analysis, the highest MCV tertile was associated with higher MACEs in whole ([HR] 1.870, 95% CI 1.113-3.144, P = 0.018), especially those non-DM ([HR] 2.089, 95% CI 1.077-4.501, P = 0.029) patients after adjustment of several cardiovascular risk factors. MCV did not predict MACEs in DM patients. During landmark analysis, admission MCV showed better predictive value for MACEs in the first 32 months of follow-up than in the subsequent period. Finally, the receiver operating characteristic (ROC) curve was conducted to confirmed the value of admission MCV within 32 months.

Conclusion

In patients with ACS, elevated admission MCV is an important and independent predictor for MACEs following stent implantation, especially amongst those without DM even after adjusting for lifestyle and clinical risk factors. However, as the follow-up period increased, the admission MCV lost its ability to predict MACEs.

Pharmaceutical care-based interventions in type 2 diabetes mellitus : a systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

To investigate the impact of pharmaceutical care-based interventions on type 2 diabetes mellitus .

METHODS

PubMed®, Cochrane and Web of Science data bases were searched for randomized controlled clinical trials. Studies evaluating pharmaceutical care-based interventions in type 2 diabetes mellitus published between 2012 and 2017 were included. Glycated hemoglobin was defined as the primary endpoint; blood pressure, triglycerides and cholesterol as secondary endpoints. The random effects model was used in meta-analysis.

RESULTS

Fifteen trials involving 2,325 participants were included. Meta-analysis revealed considerable heterogeneity (I2>97%; p<0.001), reduction in glycated hemoglobin (-1.07%; 95%CI: -1.32; -0.83; p<0.001), glucose (-29.91mg/dL; 95%CI: -43.2; -16.6; p<0.001), triglyceride (19.8mg/dL; 95%CI: -36.6; -3.04; p=0.021), systolic blood pressure (-4.65mmHg; 95%CI: -8.9; -0.4; p=0.032) levels, and increased HDL levels (4.43mg/dL; 95%CI: 0.16; 8.70; p=0.042).

CONCLUSION

Pharmaceutical care-based clincal and education interventions have significant impact on type 2 diabetes mellitus . The tools Summary of Diabetes Self-Care Activities and the Morisky Medication Adherence Scale may be useful to monitor patients.

Performance of Point-of-Care Testing Compared with the Standard Laboratory Diagnostic Test in the Measurement of HbA1c in Indonesian Diabetic and Nondiabetic Subjects

OBJECTIVE

This study is aimed at investigating if point-of-care testing for HbA1c (POCT-HbA1c) using the HemoCue® HbA1c 501 system could be an alternative method for diabetes screening and monitoring to replace the HbA1c measurement in a standard diagnostic laboratory.

DESIGN

This was a cross-sectional study to assess the agreement between POCT and a standard laboratory measurement method for determining the level of HbA1c. Setting and Participants. In total, 108 participants were recruited to participate in this study, consisting of 61 diabetics and 47 nondiabetics. The diabetic group comprised 37 females and 24 males, diagnosed with type 2 diabetes mellitus (DM) and undergoing diabetes treatment at several community health care centres in Bandung, West Java. The nondiabetic group consisted of 15 female and 32 male patients of several community health care centres and healthy volunteers. Sample Collection and Analysis. A venous blood sample was taken for routine HbA1c analysis by the diagnostic laboratory method. For the POCT-HbA1c, a blood sample was taken from the fingertip at the same time and analysed with the HemoCue® HbA1c 501 system. Outcome Measures. The HbA1c results of both methods were compared and analysed with a Bland-Altman agreement plot. The sensitivity and specificity of the POCT-HbA1c data were also compared with those of the standard diagnostic results.

RESULTS

Based on the Bland-Altman plot, the HbA1c level for 100 out of 108 (92.59%) subjects analysed by the POCT-HbA1c was within the range of the 95% limit of agreement. Compared with the standard diagnostic assay, the sensitivity of the POCT-HbA1c was 97.83% and its specificity was 77.42%.

CONCLUSIONS

The high sensitivity and accuracy of POCT-HbA1c indicate that it is a potential method for diabetes screening and monitoring to replace the routine diagnostic laboratory HbA1c measurement, especially when a rapid result is required.

Gestational diabetes mellitus diagnosed at 24 to 28 weeks of gestation in older and obese Women: Is it too late?

Aim/Background

The prevalence of elderly pregnancy and maternal obesity is increasing worldwide. In old and obese women, metabolic derangement affecting fetal growth might be present earlier than the diagnosis of gestational diabetes mellitus (GDM) or even before pregnancy. We thus investigated whether GDM diagnosed at 24–28 weeks of gestation had already affected fetal abdominal growth and, if so, whether elderly pregnancy and/or maternal obesity aggravate fetal abdominal obesity.

Methods

We retrospectively reviewed the medical records of 7820 singleton pregnant women who had been universally screened using a 50-g glucose challenge test (GCT) at 24–28 weeks of gestation, and underwent a 3-h 100-g oral glucose tolerance test (OGTT) if GCT were ≥140mg/dl. GDM and normal glucose tolerance (NGT) were diagnosed using the Carpenter-Coustan criteria. Fetal abdominal obesity was investigated by assessing the fetal abdominal overgrowth ratios (FAORs) of the ultrasonographically estimated gestational age (GA) of abdominal circumference per actual GA by the last menstruation period, biparietal diameter or femur length, respectively. Fetal abdominal overgrowth was defined as FAOR ≥ 90^th percentile. The subjects were divided into four study groups: group 1 (age < 35 years and pre-pregnancy body mass index [BMI] < 25 kg/m²), group 2 (age < 35 years and ≥ 25), group 3 (age ≥ 35 years and BMI < 25), and group 4 (age ≥ 35 years and ≥ 25).

Results

The overall prevalence of GDM was 5.1%, with old and obese group 4 exhibiting the highest prevalence (22.4%). FAORs were significantly higher in the fetus of those with GDM than in the NGT subjects. But, in the subgroup analysis, only old and nonobese group 3 and old and obese group 4 with GDM exhibited significantly higher FAORs than the NGT subjects. Also, risk of fetal abdominal overgrowth was increased in group 3 and 4 subjects with GDM but not in young and nonobese group 1 GDM. The risk of fetal abdominal overgrowth significantly increased with maternal age >35 years, pre-pregnancy BMI >20kg/m², and HbA1c >37.7 mmol/mol (5.6%). In multivariate analyses, maternal age and HbA1c were significantly associated with FAORs.

Conclusion

GDM diagnosed at 24–28 weeks of gestation already affected fetal abdominal obesity in older and/or obese women, but not in younger and nonobese women. Our data suggest that selective screening and appropriate intervention of GDM earlier than 24–28 weeks of gestation might be necessary for high-risk old and/or obese women.

Importance of Hemoglobin A1c Levels for the Detection of Post-Surgical Infection Following Single-Level Lumbar Posterior Fusion in Patients with Diabetes

Objective

Several studies have reported that patients with diabetes mellitus (DM) are vulnerable to infection. However, the mechanism underlying this remains unclear. We hypothesized that preoperative blood glucose levels in patients with DM may be a risk factor for surgical site infection (SSI). We aimed to investigate the relationship between hemoglobin A1c (HbA1c) level and SSI incidence following single-level spinal fusion surgery.

Methods

Patients with DM who underwent single-level lumbar posterior fusion surgery were retrospectively reviewed. Ninety-two patients were included and classified into the SSI and SSI-free groups. Clinical data with demographic findings were obtained and compared. The HbA1c cut-off value was defined using receiver operating characteristic (ROC) and area under the curve (AUC) analyses, which showed a significantly increased SSI risk. Potential variables were verified using multiple logistic regression analysis.

Results

Among the enrolled patients, 24 had SSI and 68 did not within 1 year. The preoperative HbA1c level was higher in patients with SSI (6.8%) than in the non-infected patients (6.0%; p=0.008). ROC analysis showed that if the HbA1c level is higher than 6.9%, the risk of SSI significantly increases (p=0.003; AUC, 0.708; sensitivity, 62.5%; specificity, 70.6%). The preoperative HbA1c level was significantly correlated with SSI incidence, after adjusting for potential variables (p=0.008; odds ratio, 4.500; 95% confidence interval, 1.486-13.624).

Conclusion

The HbA1c level, indicating glycemic control, in patients with DM may be a risk factor for SSI in single-level lumbar spine posterior fusion.

The Challenges of Iran's Type 2 Diabetes Prevention and Control Program

Background:

Incidence and prevalence of type 2 diabetes are one of the major challenges of Iran health system. Despite policies on diabetes prevention and control, Iran is faced with many problems in prevention and control of this disease at the executive level. This study seeks to identify the problems of Type 2 diabetes prevention and control program in Iran.

Methods:

In this qualitative study, 17 participants were interviewed purposefully. The semi-structured interview guide was designed based on literature review and four initial in-depth interviews. Framework analysis method was used for the analysis of qualitative data.

Results:

Six themes and 29 subthemes explaining the problems of type 2 diabetes prevention and control program were identified: Referral system, human resources, infrastructure, cultural problems, access, and intersectoral coordination issues.

Conclusions:

Despite the well-developed policy of type 2 diabetes prevention and control, the implementation is faced with some problems which endangers the effectiveness of the plan. Any attempt to improve the successful implementation of the type 2 diabetes prevention and control program requires effective measures, deep understanding of the problems and solving them.

Managing dyslipidemia for CVD prevention: A review of recent clinical practice guidelines

The American Association of Clinical Endocrinology and the American College of Endocrinology Clinical Practice Guideline is a comprehensive, practical tool that can be used to diagnose and manage dyslipidemia, a major risk for the development and progression of atherosclerotic cardiovascular disease. Effective therapies are available to improve lipid profiles and reduce cardiovascular events.

Development and Implementation of a Subcutaneous Insulin Clinical Decision Support Tool for Hospitalized Patients

BACKGROUND

Insulin is one of the highest risk medications used in hospitalized patients. Multiple complex factors must be considered in determining a safe and effective insulin regimen. We sought to develop a computerized clinical decision support (CDS) tool to assist hospital-based clinicians in insulin management.

METHODS

Adapting existing clinical practice guidelines for inpatient glucose management, a design team selected, configured, and implemented a CDS tool to guide subcutaneous insulin dosing in non-critically ill hospitalized patients at two academic medical centers that use the EpicCare® electronic medical record (EMR). The Agency for Healthcare Research and Quality (AHRQ) best practices in CDS design and implementation were followed.

RESULTS

A CDS tool was developed in the form of an EpicCare SmartForm, which generates an insulin regimen by integrating information about the patient's body weight, diabetes type, home and hospital insulin requirements, and nutritional status. Total daily recommended insulin doses are distributed into respective basal and nutritional doses with a tailored correctional insulin scale. Preimplementation, several approaches were used to communicate this new tool to clinicians, including emails, lectures, and videos. Postimplementation, a support team was available to address user technical issues. Feedback from stakeholders has been used to continuously refine the tool. Inclusion of the programming in the EMR vendor's community library has allowed dissemination of the tool outside our institution.

CONCLUSIONS

We have developed an EMR-based tool to guide SQ insulin dosing in non-critically ill hospitalized patients. Further studies are needed to evaluate adoption and clinical effectiveness of this intervention.

Baseline plasma fibrinogen is associated with haemoglobin A1c and 2-year major adverse cardiovascular events following percutaneous coronary intervention in patients with acute coronary syndrome: a single-centre, prospective cohort study

BACKGROUND

Despite revascularisation, a large proportion of acute coronary syndrome (ACS) patients continue to experience major adverse cardiovascular events (MACEs), which are worsened by diabetes mellitus (DM). Fibrinogen (FIB) is a risk factor for MACEs in coronary artery disease and often elevated in DM. However, the relationships between FIB, glucose metabolism (haemoglobin A1c [HbA1c] and fasting blood glucose [FBG]) and MACEs following percutaneous coronary intervention (PCI) in DM, non-DM or whole patients with ACS remains unknown.

METHODS

A total of 411 ACS patients undergoing PCI were enrolled in this study. We compared baseline FIB levels between DM (n = 103) and non-DM (n = 308) patients and divided participants into three groups according to FIB level, i.e. FIB-L, FIB-M and FIB-H, to compare baseline characteristics and MACEs. Linear regression analysis of the relationship between glucose metabolism and FIB, Cox regression, survival and landmark analyses of MACEs were also performed over a median of 27.55 months of follow-up.

RESULTS

Patients with DM had higher FIB levels than non-DM patients (3.56 ± 0.99 mg/dL vs. 3.34 ± 0.80 mg/dL, P < 0.05). HbA1c and FBG were significantly positively correlated with FIB in whole and DM patients but not in non-DM patients (all P < 0.05). Compared with the FIB-L group, the FIB-M (hazard ratio [HR] 1.797, 95% CI 1.117-2.892, P = 0.016) and FIB-H (HR 1.664, 95% CI 1.002-2.763, P = 0.049) groups were associated with higher MACEs in whole; the FIB-M (HR 7.783, 95% CI 1.012-59.854, P = 0.049) was associated with higher MACEs in DM patients. FIB was not associated with MACEs in non-DM patients. During landmark analysis, FIB showed better predictive value for MACEs after PCI in the first 30 months of follow up than in the subsequent period.

CONCLUSION

In this study from China, FIB was positively associated with glucose metabolism (HbA1c and FBG) in whole and DM populations with ACS. Moreover, elevated baseline FIB levels may be an important and independent predictor of MACEs following PCI, especially amongst those with DM. However, as the follow-up period increased, the baseline FIB levels lost their ability to predict MACEs.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF DYSLIPIDEMIA AND PREVENTION OF CARDIOVASCULAR DISEASE

OBJECTIVE

The development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).

METHODS

Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols.

RESULTS

The Executive Summary of this document contains 87 recommendations of which 45 are Grade A (51.7%), 18 are Grade B (20.7%), 15 are Grade C (17.2%), and 9 (10.3%) are Grade D. These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world medical care. The evidence base presented in the subsequent Appendix provides relevant supporting information for Executive Summary Recommendations. This update contains 695 citations of which 203 (29.2 %) are EL 1 (strong), 137 (19.7%) are EL 2 (intermediate), 119 (17.1%) are EL 3 (weak), and 236 (34.0%) are EL 4 (no clinical evidence).

CONCLUSION

This CPG is a practical tool that endocrinologists, other health care professionals, health-related organizations, and regulatory bodies can use to reduce the risks and consequences of dyslipidemia. It provides guidance on screening, risk assessment, and treatment recommendations for a range of individuals with various lipid disorders. The recommendations emphasize the importance of treating low-density lipoprotein cholesterol (LDL-C) in some individuals to lower goals than previously endorsed and support the measurement of coronary artery calcium scores and inflammatory markers to help stratify risk. Special consideration is given to individuals with diabetes, familial hypercholesterolemia, women, and youth with dyslipidemia. Both clinical and cost-effectiveness data are provided to support treatment decisions.

ABBREVIATIONS

4S = Scandinavian Simvastatin Survival Study A1C = glycated hemoglobin AACE = American Association of Clinical Endocrinologists AAP = American Academy of Pediatrics ACC = American College of Cardiology ACE = American College of Endocrinology ACS = acute coronary syndrome ADMIT = Arterial Disease Multiple Intervention Trial ADVENT = Assessment of Diabetes Control and Evaluation of the Efficacy of Niaspan Trial AFCAPS/TexCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study AHA = American Heart Association AHRQ = Agency for Healthcare Research and Quality AIM-HIGH = Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides trial ASCVD = atherosclerotic cardiovascular disease ATP = Adult Treatment Panel apo = apolipoprotein BEL = best evidence level BIP = Bezafibrate Infarction Prevention trial BMI = body mass index CABG = coronary artery bypass graft CAC = coronary artery calcification CARDS = Collaborative Atorvastatin Diabetes Study CDP = Coronary Drug Project trial CI = confidence interval CIMT = carotid intimal media thickness CKD = chronic kidney disease CPG(s) = clinical practice guideline(s) CRP = C-reactive protein CTT = Cholesterol Treatment Trialists CV = cerebrovascular CVA = cerebrovascular accident EL = evidence level FH = familial hypercholesterolemia FIELD = Secondary Endpoints from the Fenofibrate Intervention and Event Lowering in Diabetes trial FOURIER = Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects With Elevated Risk trial HATS = HDL-Atherosclerosis Treatment Study HDL-C = high-density lipoprotein cholesterol HeFH = heterozygous familial hypercholesterolemia HHS = Helsinki Heart Study HIV = human immunodeficiency virus HoFH = homozygous familial hypercholesterolemia HPS = Heart Protection Study HPS2-THRIVE = Treatment of HDL to Reduce the Incidence of Vascular Events trial HR = hazard ratio HRT = hormone replacement therapy hsCRP = high-sensitivity CRP IMPROVE-IT = Improved Reduction of Outcomes: Vytorin Efficacy International Trial IRAS = Insulin Resistance Atherosclerosis Study JUPITER = Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin LDL-C = low-density lipoprotein cholesterol Lp-PLA2 = lipoprotein-associated phospholipase A2 MACE = major cardiovascular events MESA = Multi-Ethnic Study of Atherosclerosis MetS = metabolic syndrome MI = myocardial infarction MRFIT = Multiple Risk Factor Intervention Trial NCEP = National Cholesterol Education Program NHLBI = National Heart, Lung, and Blood Institute PCOS = polycystic ovary syndrome PCSK9 = proprotein convertase subtilisin/kexin type 9 Post CABG = Post Coronary Artery Bypass Graft trial PROSPER = Prospective Study of Pravastatin in the Elderly at Risk trial QALY = quality-adjusted life-year ROC = receiver-operator characteristic SOC = standard of care SHARP = Study of Heart and Renal Protection T1DM = type 1 diabetes mellitus T2DM = type 2 diabetes mellitus TG = triglycerides TNT = Treating to New Targets trial VA-HIT = Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial VLDL-C = very low-density lipoprotein cholesterol WHI = Women's Health Initiative.

Do patients with diabetes use the insulin pen properly?

AIM

This study was conducted to evaluate the insulin pen application knowledge and skills of patients with diabetes.

METHODS

In our descriptive study, 200 patients with diabetes were asked to present the insulin pen injection technique on a mannequin and the steps of the pen injection implementation were noted on the data collection form as correct/incorrect by researchers.

RESULTS

More than 3 out of 4 (79.5%) of the participants were using the insulin pen or the cartridge after the expiry date, 70.5% were not rotating the injection site, and 63.0% were massaging the skin after injection. Injection sites complications were significantly more in those who were using the insulin pen or the cartridge after the expiry date, those who don't know the proper length of the needle and the possible body injection sites, those who don't rotate the injection sites, those who massage after injection, and those who don't use a new needle at each injection (p<0.05).

CONCLUSION

This study put into light some failures in the knowledge and skills of patients with diabetes regarding insulin pen use. Nurses should provide patients with diabetes an effective and repetitive training concerning insulin pen use.

Is calcitonin gene-related peptide a modulator of menopausal vasomotor symptoms?

PURPOSE

Calcitonin gene-related peptide (CGRP) is a neuropeptide widely distributed in the central and peripheral nervous systems, which is known as a potent vasodilator. Postmenopausal women who experience hot flushes have high levels of plasma CGRP, suggesting its involvement in menopausal vasomotor symptoms.

METHODS

In this review, we describe the biochemical aspects of CGRP and its effects associated with deficiencies of sexual hormones on skin temperature, vasodilatation, and sweating as well as the possible peripheral and central mechanisms involved in these events.

RESULTS

Several studies have shown that the effects of CGRP on increasing skin temperature and inducing vasodilatation are potentiated by a deficiency of sex hormones, a common condition of postmenopausal women. Additionally, the medial preoptic area of the hypothalamus, involved in thermoregulation, contains over 25-fold more CGRP-immunoreactive cells in female rodents compared with male rodents, reinforcing the role of female sex hormones on the action of CGRP. Some studies suggest that ovarian hormone deficiency decreases circulating endogenous CGRP, inducing an upregulation of CGRP receptors. Consequently, the high CGRP receptor density, especially in blood vessels, amplifies the stimulatory effects of this neuropeptide to raise skin temperature in postmenopausal women during hot flushes.

CONCLUSIONS

The duration of the perception of each hot flush in a woman is brief, while local reddening after intradermal administration of α-CGRP persists for 1 to 6 h. This contrast remains unclear.

Critical appraisal and systematic review of guidelines for perioperative diabetes management: 2011-2017

PURPOSE

To systematically evaluate the quality, consistency and the evidence support of guidelines for perioperative diabetes management.

METHODS

We retrieved guidelines through systematic search, critically evaluated their quality and compared the recommendations of included guidelines. Five aspects were compared: target level, management of hyper- and hypoglycaemia, frequency of monitoring, management of insulin, and management of oral anti-diabetic drugs (OADs).

RESULTS

Fourteen guidelines met our criteria, and 342 recommendations were extracted, the results of Appraisal of Guidelines for Research and Evaluation II (AGREE II) evaluation showed that none of the mean score in each domain was higher than 50%. On average, most guidelines had only one domain scored above 50%. Most recommendations (78.9%) did not specify their supporting evidence, 71 (20.8%) were formed using grading criteria, none cited systematic review or meta-analysis. Recommendations were inconsistent across different guidelines.

CONCLUSIONS

The existing guidelines about perioperative management of diabetes needs improvement in methodology, as well as the production of evidence with high quality. Evidence-based guidelines are required for the perioperative management of diabetes.

Experience after switching from insulin glargine U100 to glargine U300 in patients with type 1 diabetes mellitus. A study after one year of treatment in real life

INTRODUCTION

Current treatment of type 1 diabetes mellitus (T1DM) does not always achieve metabolic control because, among other things, the ocurrence of hypoglycemic events associated to insulin use.

MATERIAL AND METHODS

A descriptive real life study of 247 T1DM patients, 55.5% male, aged 46.53 ± 16.23 years, and with a mean diabetes duration of 21.89 ± 11.99 years, who were switched from basal insulin glargine U100 to glargine U300. The primary endpoints were changes in Hba1c and number of hypoglycemic events, while secondary endpoints included changes in weight and insulin dose after 6 and 12 months.

RESULTS

After one year, no changes were seen in HbA1c, but the proportion of patients with HbA1c values <7.5% increased at 6 months (33.5 vs. 40.5%; P<0.05) and remained stable during one year of follow-up. Hypoglycemic events significantly decreased after one year of treatment in patients with previous hypoglycemic events. No changes were seen in body weight. Total insulin dose (U/kg) increased 7.24% at 6 months of treatment and by 8.69% at one year, mainly due to basal insulin. No changes were seen between the doses given at 6 and 12 months. These changes were similar in the different metabolic control groups and in patients with or without hypoglycemia. This increase was not related with prior basal insulin dose, baseline HbA1c level, number of hypoglycemic events or baseline weight.

DISCUSSION

Glargine U300 is a good basal insulin alternative to treat T1DM, improving metabolic control in patients with HbA1c levels >7,5 and decreasing hypoglycemic events in patients with history of hypoglycemia without increasing body weight.

Effect of inositol stereoisomers at different dosages in gestational diabetes: an open-label, parallel, randomized controlled trial

AIMS

Gestational diabetes mellitus (GDM) is the most common metabolic disorder of pregnancy. The aim of the study is to compare the effect of different dosages of inositol stereoisomers supplementation on insulin resistance levels and several maternal-fetal outcomes in GDM women.

METHODS

Participants were randomly allocated to receive daily: 400 mcg folic acid (control treatment), 4000 mg myo-inositol plus 400 mcg folic acid (MI treatment), 500 mg D-chiro-inositol plus 400 mcg folic acid (DCI treatment) or 1100/27.6 mg myo/D-chiro-inositol plus 400 mcg folic acid (MI plus DCI treatment). The homeostasis model assessment of insulin resistance (HOMA-IR) was measured at the diagnosis of GDM and after 8 weeks of treatment. Secondary outcomes, obstetric outcomes and any maternal or fetal complication at delivery were also collected.

RESULTS

Eighty GDM women were assigned to one of the four arms of study (20 per arm). A significant delta decrease in HOMA-IR index was found in subjects of MI group without insulin therapy compared to control group (p < 0.001). A lower variation in average weight gain (at delivery vs pre-pregnancy and OGTT period) was detected in MI group vs control group (p = 0.001 and p = 0.019, respectively). Moreover, women exposed to MI and MI plus DCI required a significantly lower necessity of an intensified insulin treatment. Women of the control group had newborns with higher birth weight compared with women treated with inositol (p = 0.032).

CONCLUSIONS

Our study provides interesting but preliminary results about the potential role of inositol stereoisomers supplementation in the treatment of GDM on insulin resistance levels and several maternal-fetal outcomes. Further studies are required to examine the optimal and effective dosages of different inositol supplements. CLINICAL TRIAL REG. NO.: NCT02097069, ClinicalTrial.gov.

Exercise and Diabetes: A Narrative Review

Persons with diabetes might experience significant benefits through regular exercise. Not unlike the general population, those with diabetes could also lack motivation to participate in an exercise program. Often, those treating persons with diabetes lack training and/or interest in exercise prescription and are therefore unable to provide the needed information and encouragement. In many cases, reluctance to exercise could result from an inability to find an enjoyable exercise activity. Attempts to find activities that, not only provide effective aerobic challenges, but are also enjoyable to participate in are fraught with difficulty. Three electronic databases were searched in January 2017. Evidence for the merits of exercise for those with diabetes was robust. Numerous reports have addressed the degree of noncompliance to exercise recommendations and the barriers reported for this nonadherence. Additional studies concluded that most medical providers are deficient in formal training in the prescription of an exercise program. Newer studies are evaluating the effects of exercise and vitamin D supplementation and their interplay with diabetic peripheral neuropathy and ulceration. Exercise confers remarkable benefits to those with diabetes; however, the challenges to compelling patients with diabetes to exercise are formidable. An improved focus on exercise prescription and related motivation during provider training must be undertaken.

The Impact of Biofilm Formation on the Persistence of Candidemia

This study aimed to determine the predictors of persistent candidemia and examine the impact of biofilm formation by Candida isolates in adult patients with candidemia. Of the adult patients with candidemia in Kaohsiung Chang Gung Memorial Hospital between January 2007 and December 2012, 68 case patients with persistent candidemia (repeated candidemia after a 3-day systemic antifungal therapy) and 68 control patients with non-persistent candidemia (Candida clearance from the bloodstream after a 3-day systemic antifungal therapy) were included based on propensity score matching and matching for the Candida species isolated. Biofilm formation by the Candida species was assessed in vitro using standard biomass assays. Presence of central venous catheters (CVCs) at diagnosis (adjusted odd ratio [AOR], 3.77; 95% confidence interval [CI], 1.09–13.00, p = 0.04), infection with higher biofilm forming strains of Candida species (AOR, 8.03; 95% CI, 2.50–25.81; p < 0.01), and receipt of suboptimal fluconazole doses as initial therapy (AOR, 5.54; 95% CI, 1.53–20.10; p < 0.01) were independently associated with persistent candidemia. Biofilm formation by Candida albicans, C. tropicalis, and C. glabrata strains was significantly higher in the case patients than in the controls. There were no significant differences in the overall mortality and duration of hospitalization between the two groups. Our data suggest that, other than presence of retained CVCs and use of suboptimal doses of fluconazole, biofilm formation was highly associated with development of persistent candidemia.

Mortality from type 2 diabetes and implementation of the PREVENIMSS program: a time series study in Mexico, 1998-2015

Type 2 diabetes is the leading cause of morbidity and mortality in the world. In Mexico it is the first cause of mortality, disability, and potential years of life lost due to premature death. The Mexican Institute of Social Security (IMSS) implemented the PREVENIMSS strategy. The aim of the current study was to estimate the program's effect on the mortality trend from type 2 diabetes, based on an interrupted time series analysis. At the beginning of the target period, the diabetes mortality rate was higher in IMSS beneficiaries than in the control population. After the program's implementation, there was a slight reduction in the mortality trend, while the control group showed an upward trend. Differences in the trends between the two groups suggest that they are not the exclusive result of institutional interventions. Living and work conditions could explain these differences.

Investigation of Motivational Interviewing and Prevention Consults to Achieve Cardiovascular Targets (IMPACT) trial

BACKGROUND

Patients undergoing cardiovascular (CV) procedures often have suboptimal CV risk factor control and may benefit from strategies targeting healthy lifestyle behaviors and education. Implementation of prevention strategies may be particularly effective at this point of heightened motivation.

METHODS

A prospective, randomized, pilot study was conducted in 400 patients undergoing a nonurgent CV procedure (cardiac catheterization ± revascularization) to evaluate the impact of different prevention strategies. Patients were randomized in a 1:1:1 fashion to usual care (UC; group A, n = 134), in-hospital CV prevention consult (PC; group B, n = 130), or PC plus behavioral intervention program (telephone-based motivational interviewing and optional tailored text messages) (group C, n = 133). The primary end point was the Δ change in non-high-density lipoprotein cholesterol (non-HDL-C) from baseline to 6 month.

RESULTS

The mean age was 64.6 ± 10.8 years, 23.7% were female, and 31.5% were nonwhite. After 6 months, the absolute difference in non-HDL-C for all participants was -19.8 mg/dL (95% CI -24.1 to -15.6, P < .001). There were no between-group differences in the primary end point for the combined PC groups (B and C) versus UC, with a Δ adjusted between group difference of -5.5 mg/dL (95% CI -13.1 to 2.1, P = .16). Patients in the PC groups were more likely to be on high-intensity statins at 6 months (52.9% vs 38.1%, P = .01). After excluding participants with baseline non-HDL-C <100 mg/dL (initial exclusion criterion), Δ non-HDL-C and Δ low-density lipoprotein cholesterol were improved in the PC groups compared to UC (non-HDL-C -8.13 mg/dL [-16.00 to -0.27], P = .04; low-density lipoprotein cholesterol -7.87mg/dL [-15.10 to -0.64], P = .03).

CONCLUSIONS

Although non-HDL-C reduction at 6 months following a nonurgent CV procedure was not significant in the overall cohort, an increased uptake in high-potency statins may translate into improved long-term health outcomes and cost reductions.

Adherence to the American Diabetes Association retinal screening guidelines for population with diabetes in the United States

PURPOSE

(1) To assess long-term adherence to American Diabetes Association guideline-recommended retinal screening among population with diabetes in the United States. (2) To determine factors associated with long-term adherence to routine eye screening exams.

METHODS

A retrospective cohort study was conducted in adult patients with diabetes identified from January 2009 to December 2010. Patients were followed until disenrollment, death, or study end date (December 2013). A patient was defined as adherent when having at least one exam in each 12-month period if there was evidence of retinopathy, or at least one exam in each 24-month period if there was no evidence of retinopathy. Multivariate logistic regressions were used to investigate patient demographics and other baseline characteristics associated with adherence to guidelines.

RESULTS

A total of 204,073 patients were identified; the mean age (SD) was 61 (13) years and 48% were female. Overall, 71.1% were adherent to the retinal screening guidelines during a median of 4.8 years of follow-up including 27.7% who received an eye exam every year. Patient socioeconomic status (younger age, black race, lower income/education), less comorbidity, insulin use, higher specialist copayment plans, and proxies for poor patient behavior (lower adherence to the oral hypoglycemic agents, less diabetes education, hemoglobin A1C >9%) were associated with nonadherence to routine eye screening exams.

CONCLUSION

During nearly 5 years of follow-up, 28.9% of patients with diabetes were nonadherent to the retinal screening guidelines. Future research should focus on the development of interventions to address modifiable factors associated with nonadherence.

The postpartum effect of maternal diabetes on the circulating levels of sirtuins and superoxide dismutase

Gestational diabetes mellitus (GDM) is a glucose intolerance disorder which occurs during pregnancy as a result of insulin insensitivity; it usually disappears after delivery. However, some women with GDM can develop type 2 diabetes (T2D) after delivery, and the mechanisms by which this occurs remain unknown. This study compared the levels of sirtuins (NAD‐dependent deacetylases) and antioxidative enzymes in postpartum women with previous GDM (pGDM) or T2D and in postpartum women with a previous healthy pregnancy (controls). Women with pGDM showed upregulated levels of sirtuin 1 (SIRT1) mRNA and protein, with reduced expression levels of sirtuin 3 (SIRT3) and superoxide dismutase 2 (SOD2), relative to the controls. Women with T2D similarly showed a lower level of SIRT3 mRNA than the controls. Lipid peroxidation (malondialdehyde) was higher in women with pGDM than in the controls. These data show that in women with pGDM, the reduced level of SIRT3 may play a role in the reduced SOD2 level, possibly leading to oxidative stress, which, in turn, upregulates the level of SIRT1. These results might confer the risk of future diabetes development in women with pGDM, as a similar reduction in SIRT3 was found in women with T2D.

Oroxin A from Oroxylum indicum prevents the progression from prediabetes to diabetes in streptozotocin and high-fat diet induced mice

BACKGROUND

Oroxylum indicum (L.) Kurz (Bignoniaceae) has been widely used for the treatment of respiratory infections and gastrointestinal disorders. Our previous study showed that an ethanol-water O. indicum seed extract (OISE), when combined with acarbose, reduced the risk of diabetes by 75% and effectively prevented the associated complications. Oroxin A, a major component of OISE, can activate PPARγ and inhibit α-glucosidase and it represents a promising candidate for diabetes intervention.

PURPOSE

The aim of this study is to investigate the effect of oroxin A from O. indicum on the progression of prediabetes to diabetes and the underlying mechanisms in streptozotocin and high-fat-diet induced prediabetic mice.

METHODS

Oroxin A was purified from OISE and its PPARγ transcriptional activation was determined in vitro and in vivo. The prediabetic mice were established by high-fat diet and streptozotocin, which was followed by treatment with oroxin A. The effect of oroxin A was determined by analysis of the lipid profiles, oxidative stress, hepatic function and histology. The mechanism of oroxin A was also investigated.

RESULTS

Oroxin A is a compound with low toxicity that has reduced the relative risk of progression from prediabetes to diabetes by 66.7% without inducing weight gain or hepatotoxicity. Oroxin A also improved the complications of prediabetes, such as lipid metabolism dysfunction and liver injury. Results of mechanism studies suggested that oroxin A is a partial PPARγ agonist that can activate PPARγ transcriptional activation in vitro and in vivo. Oroxin A also exhibited an inhibitory activity against α-glucosidase and an antioxidant capacity.

CONCLUSION

Oroxin A prevents the progression from prediabetes to diabetes through a multi-pathway intervention mechanism.

Targeting erythropoietin protects against proteinuria in type 2 diabetic patients and in zebrafish

Objective

Adult human kidneys produce erythropoietin (EPO), which regulates red blood cell formation; however, whether EPO also functions directly on kidney development and controls diabetic kidney disease remains unknown. Here we analyzed the role of EPO in kidney development and under hyperglycemic conditions in zebrafish and in humans.

Methods

Diabetic patients and respective controls were enrolled in two cohorts. Serum EPO level and urine protein change upon human EPO administration were then analyzed. Transient knockdown and permanent knockout of EPO and EPOR in renal TG(WT1B:EGFP) zebrafish were established using the morpholino technology and CRISPR/Cas9 technology. Zebrafish embryos were phenotypically analyzed using fluorescence microscopy, and functional assays were carried out with the help of TexasRed labeled 70 kDa Dextran. Apoptosis was determined using the TUNEL assay and Annexin V staining, and caspase inhibitor zVADfmk was used for rescue experiments.

Results

In type 2 diabetic patients, serum EPO level decreased with the duration of diabetes, which was linked to reduced kidney function. Human recombinant EPO supplementation ameliorated proteinuria in diabetic nephropathy patients. In zebrafish, loss-of-function studies for EPO and EPOR, showed morphological and functional alterations within the pronephros, adversely affecting pronephric structure, leading to slit diaphragm dysfunction by increasing apoptosis within the pronephros. Induction of hyperglycemia in zebrafish embryos induced pronephros alterations which were further worsened upon silencing of EPO expression.

Conclusions

EPO was identified as a direct renal protective factor, promoting renal embryonic development and protecting kidneys from hyperglycemia induced nephropathy.

•

EPO exhibited renal protective and proteinuria ameliorating function in type 2 DM patients and in hyperglycemic zebrafish embryos.

•

Enhanced co-expression of EPO and EPOR was identified in both glomeruli and tubuli of DN patients.

•

EPO and its receptor directly regulate physiological kidney development via repressing apoptosis.

High Fasting Plasma Glucose during Early Pregnancy: A Review about Early Gestational Diabetes Mellitus

Fasting plasma glucose (FPG) is nowadays routinely measured during early pregnancy to detect preexisting diabetes (FPG ≥ 7 mmol/L). This screening has concomitantly led to identify early intermediate hyperglycemia, defined as FPG in the 5.1 to 6.9 mmol/L range, also early gestational diabetes mellitus (eGDM). Early FPG has been associated with poor pregnancy outcomes, but the recommendation by the IADPSG to refer women with eGDM for immediate management is more pragmatic than evidence based. Although eGDM is characterized by insulin resistance and associated with classical risk factors for type 2 diabetes and incident diabetes after delivery, it is not necessarily associated with preexisting prediabetes. FPG ≥ 5.1 mmol/L in early pregnancy is actually poorly predictive of gestational diabetes mellitus diagnosed after 24 weeks of gestation. An alternative threshold should be determined but may vary according to ethnicity, gestational age, and body mass index. Finally, observational data suggest that early management of intermediate hyperglycemia may improve prognosis, through reduced gestational weight gain and potential early introduction of hypoglycemic agents. Considering all these issues, we suggest an algorithm for the management of eGDM based on early FPG levels that would be measured in case of risk factors. Nevertheless, interventional randomized trials are still missing.

Maternal and fetal blood lipid concentrations during pregnancy differ by maternal body mass index: findings from the ROLO study

Background

Pregnancy is a time of altered metabolic functioning and maternal blood lipid profiles change to accommodate the developing fetus. While these changes are physiologically necessary, blood lipids concentrations have been associated with adverse pregnancy outcomes such as gestational diabetes, pregnancy-induced hypertension and high birth weight. As blood lipids are not routinely measured during pregnancy, there is limited information on what is considered normal during pregnancy and in fetal blood.

Methods

Data from 327 mother-child pairs from the ROLO longitudinal birth cohort study were analysed. Fasting total cholesterol and triglycerides were measured in early and late pregnancy and fetal cord blood. Intervals were calculated using the 2.5th, 50th and 97.5th centile. Data was stratified based on maternal body mass index (BMI) measured during early pregnancy. Differences in blood lipids between BMI categories were explored using ANOVA and infant outcomes of macrosomia and large-for-gestational-age (LGA) were explored using independent student T-tests and binary logistic regression.

Results

All maternal blood lipid concentrations increased significantly from early to late pregnancy. In early pregnancy, women with a BMI < 25 kg/m² had lower concentrations of total cholesterol compared to women with a BMI of 25–29.9 kg/m² (P = 0.02). With triglycerides, women in the obese category (BMI > 30 kg/m²) had higher concentrations than both women in the normal-weight and overweight category in early and late pregnancy (P < 0.001 and P = 0.03, respectively). In late pregnancy, triglyceride concentrations remained elevated in women in the obese category compared to women in the normal-weight category (P = 0.01). Triglyceride concentrations were also elevated in late pregnancy in mothers that then gave birth to infants with macrosomia and LGA (P = 0.01 and P = 0.03, respectively).

Conclusion

Blood lipid concentrations increase during pregnancy and differ by maternal BMI. These intervals could help to inform the development of references for blood lipid concentrations during pregnancy.

Trial registration

ROLO Study - ISRCTN54392969. Date of registration: 22/04/2009.

Association of the Cardiometabolic Staging System with Individual Engagement and Quality of Life in the US Adult Population

OBJECTIVE

The aim of this study was to examine the relationships of Cardiometabolic Disease Staging (CMDS), a validated five-stage system for assessing risk for diabetes, cardiovascular mortality, and all-cause mortality, with measures of individual engagement and health-related quality of life (HRQOL) in the US adult population.

METHODS

Data from the 2011-2014 National Health and Nutrition Examination Survey were used to derive the CMDS stages, five participant engagement measures, and four HRQOL measures among adult participants ≥ 40 years of age. Analyses accounted for the complex sampling design and sample weights.

RESULTS

Higher CMDS was associated with greater participant awareness of cardiometabolic risk, but after adjusting for covariates, only Stage 4 remained significant (odds ratio: 5.08; 95% CI: 3.25, 7.94). Higher CMDS was associated with receiving recommendations to engage in a healthy lifestyle, not meeting 2008 physical activity guidelines, and fewer leisure time moderate activities after controlling for covariates. For HRQOL measures, Stage 4 was associated with a higher likelihood of perceiving health as fair or poor (odds ratio: 4.85; 95% CI: 2.42, 9.73).

CONCLUSIONS

Higher CMDS was associated with greater individual awareness of risk, less leisure time physical activity, and worse self-rated health. CMDS is a clinically practical method for identifying individuals for targeted preventive strategies.

Quality of Care of the Initial Patient Cohort of the Diabetes Collaborative Registry®

BACKGROUND

Although guidelines and performance measures exist for patients with diabetes mellitus, achievement of these metrics is not well known. The Diabetes Collaborative Registry^® (DCR) was formed to understand the quality of diabetes mellitus care across the primary and specialty care continuum in the United States.

METHODS AND RESULTS

We assessed the frequency of achievement of 7 diabetes mellitus-related quality metrics and variability across the Diabetes Collaborative Registry^® sites. Among 574 972 patients with diabetes mellitus from 259 US practices, median (interquartile range) achievement of the quality metrics across the practices was the following: (1) glycemic control: 19% (5-47); (2) blood pressure control: 80% (67-88); (3) angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in patients with coronary artery disease: 62% (51-69); (4) nephropathy screening: 62% (53-71); (5) eye examination: 0.7% (0.0-79); (6) foot examination: 0.0% (0.0-2.3); and (7) tobacco screening/cessation counseling: 86% (80-94). In hierarchical, modified Poisson regression models, there was substantial variability in meeting these metrics across sites, particularly with documentation of glycemic control and eye and foot examinations. There was also notable variation across specialties, with endocrinology practices performing better on glycemic control and diabetes mellitus foot examinations and cardiology practices succeeding more in blood pressure control and use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers.

CONCLUSIONS

The Diabetes Collaborative Registry^® was established to document and improve the quality of outpatient diabetes mellitus care. While target achievement of some metrics of cardiovascular risk modification was high, achievement of others was suboptimal and highly variable. This may be attributable to fragmentation of care, lack of ownership among various specialists concerning certain domains of care, incomplete documentation, true gaps in care, or a combination of these factors.

Hemoglobin A1c is associated with severity of coronary artery stenosis but not with long term clinical outcomes in diabetic and nondiabetic patients with acute myocardial infarction undergoing primary angioplasty

Background

Acute myocardial infarction (AMI) patients with type 2 diabetes mellitus are known to present with multiple vessel lesions during coronary angiography. The underlying mechanism remains elusive and there is a shortage of serum prediction markers. In this study, we investigate the relationship between admission HbA_1c and severity of coronary artery stenosis and subsequent prognosis in AMI patients with or without diabetes.

Research design and methods

We measured admission HbA_1c, and vessel scores based on the number of diseased coronary vessels with significant stenosis in 628 patients diagnosed with AMI. Simple and multi-regression analysis were performed to investigate the correlation between HbA_1c and the severity of coronary artery stenosis. Major adverse cardiovascular events (MACE), including new-onset myocardial infarction, acute heart failure and cardiac death, were documented during the follow-up. 272 non-DM participants and 137 DM participants were separated into two groups based on HbA_1c levels for survival analysis during a 2-year follow up.

Results

448 non-DM patients and 180 DM patients were included in the initial observational analysis. 272 non-DM patients and 137 DM patients were included in the follow-up survival analysis. The admission HbA_1c level was found to be significantly positively correlated to the number of affected vessels suffering from significant coronary artery stenosis both in DM (R square = 0.012; 95% CI 0.002 to 0.623, P = 0.049) and non DM patients (R square = 0.025; 95% CI 0.009 to 0.289, P = 0.037). Kaplan–Meier survival analysis revealed no significant difference with regard to different HbA_1c levels either in DM or non-DM patients at the end of follow-up.

Conclusions

In patients with AMI, admission HbA_1c is an important predictor for the severity of coronary artery stenosis in non-DM and DM patients. Further studies are needed to determine whether longer term follow-up could further identify the prognosis effect of HbA_1c on MACE.

A Review of the Long-Term Efficacy, Tolerability, and Safety of Exenatide Once Weekly for Type 2 Diabetes

INTRODUCTION

Exenatide once weekly (ExeOW, Bydureon®, Astra Zeneca), a drug belonging to the class of glucagon-like peptide-1 (GLP-1) receptor agonists, is the first agent approved for treatment of type 2 diabetes (T2D) that can be administered on a weekly basis.

METHODS

Data concerning treatment of T2D with ExeOW are reviewed with special reference to its long-term efficacy, tolerability, and safety. Relevant literature was identified through the PubMed database from inception to January 2015.

RESULTS

In randomized clinical trials ExeOW, as add-on to oral antidiabetics, achieved significantly improved glycemic control compared to maximum recommended doses of exenatide twice daily, sitagliptin, pioglitazone, and insulin glargine, as measured by HbA1c. In drug-naïve patients ExeOW was superior to sitagliptin and non-inferior to metformin, whereas non-inferiority to pioglitazone and liraglutide was not proven. In different trials reductions in HbA1c ranged from -1.1% to -2.0%. ExeOW therapy over 6 months was also associated with a mean weight loss of -2 to -4 kg, improved systolic blood pressure and lipid profile, and no hypoglycemia unless associated to sulfonylurea. ExeOW long-term therapy up to 3-6 years allowed persistent glycemic control (HbA1c -1.6%), sustained decreases in blood pressure (-2 mmHg), and improvements of lipid profile. ExeOW tolerability was comparable to that of the other GLP-1 receptor agonists, with better gastrointestinal tolerability when direct comparison was done (namely liraglutide and exenatide BID), but higher incidence of injection site reactions and few treatment discontinuations mainly due to gastrointestinal events.

CONCLUSION

ExeOW is a well-tolerated and convenient option for long-term treatment of T2D allowing significant and persistent glycemic control with moderate weight loss and low risk of hypoglycemia unless associated with sulfonylureas.

Dynamics of diabetes and obesity: Epidemiological perspective

The purpose of this review article is to understand the current literature on obesity, diabetes and therapeutic avenues across the world. Diabetes is a chronic lifestyle condition that affects millions of people worldwide and it is a major health concern in our society. Diabetes and obesity are associated with various conditions, including non-modifiable and modifiable risk factors. Early detectable markers are not well established to detect pre-diabetes and as a result, it becomes diabetes. Several published epidemiological studies were assessed and the findings were summarized. Resources from published studies were used to identify criteria used for pre-diabetes, the role of diet in pre-diabetics and potential risks and characteristics associated with pre-diabetes. Preventive strategies are needed to combat diabetes. Individuals diagnosed with pre-diabetes need detailed education, need to fully understand the risk factors and have the ability to manage diabetes. Interventions exist that include chronic disease self-management programs, lifestyle interventions and pharmacological strategies. Obesity plays a large role in causing pre-diabetes and diabetes. Critical analysis of existing epidemiological research data suggests that additional research is needed to determine the efficacy of interventions. This article is part of a Special Issue entitled: Oxidative Stress and Mitochondrial Quality in Diabetes/Obesity and Critical Illness Spectrum of Diseases - edited by P. Hemachandra Reddy.

Behavioral Analysis of Chinese Adult Patients with Type 1 Diabetes on Self-monitoring of Blood Glucose

BACKGROUND

The information-motivation-behavioral skills (IMB) model of health behavior is an effective tool to evaluate the behavior of diabetes self-management. The purpose of this study was to explore behavioral factors affecting the practice of self-monitoring of blood glucose (SMBG) within the frame of IMB model of health behavioral among adult patients with type 1 diabetes in a single diabetes clinic in China.

METHODS

A questionnaire with three subscales on SMBG information, motivation, and behavioral skills based on IMB model was developed. Validity and reliability of the measures were examined and guaranteed. Adult patients with type 1 diabetes visiting our diabetes clinic from January to March 2012 (n = 55) were consecutively interviewed. The self-completion questionnaires were administered and finished at face-to-face interviews among these patients. Both descriptive and correlational analyses were made.

RESULTS

Fifty-five patients finished the questionnaires, with the median duration of diabetes 4.5 years and the median of SMBG frequency 2.00. Specific SMBG information deficits, motivation obstacles, and behavioral skill limitations were identified in a substantial proportion of participants. Scores of SMBG motivation (r = 0.299, P= 0.026) and behavioral skills (r = 0.425, P= 0.001) were significantly correlated with SMBG frequency. The multiple correlation of SMBG information, SMBG motivation, and SMBG behavioral skills with SMBG frequency was R = 0.411 (R2 = 0.169, P= 0.023).

CONCLUSIONS

Adult patients with type 1 diabetes in our clinic had substantial SMBG information deficits, motivation obstacles, and skill limitations. This information provided potential-focused education targets for diabetes health-care providers.