Management of Outpatients With Diabetes at High Risk of Hypoglycemia

This JAMA Clinical Guidelines Synopsis summarizes the Endocrine Society’s 2023 recommendations on management of outpatients with diabetes and high risk of hypoglycemia.

Stress and human health in diabetes: A report from the 19th Chicago Biomedical Consortium symposium

Stress and diabetes coexist in a vicious cycle. Different types of stress lead to diabetes, while diabetes itself is a major life stressor. This was the focus of the Chicago Biomedical Consortium's 19th annual symposium, "Stress and Human Health: Diabetes," in November 2022. There, researchers primarily from the Chicago area met to explore how different sources of stress - from the cells to the community - impact diabetes outcomes. Presenters discussed the consequences of stress arising from mutant proteins, obesity, sleep disturbances, environmental pollutants, COVID-19, and racial and socioeconomic disparities. This symposium showcased the latest diabetes research and highlighted promising new treatment approaches for mitigating stress in diabetes.

Telementoring With Project ECHO: A New Era in Diabetes-Related Continuing Education for Primary Care to Address Health Disparities

Project ECHO® is a telementoring workforce development model that targets under-resourced communities lacking access to specialty care. The model builds virtual communities of practice, including specialists and community primary care professionals (PCPs) to combat clinical inertia and health disparities. While the ECHO model has gained global recognition, implementation of the model related to diabetes is lagging compared to other specialty conditions. This review highlights diabetes-endocrine (ENDO)-focused ECHOs using data reported in the ECHO Institute's centralized data repository (iECHO) and the learning collaborative for diabetes ECHOs. It also describes the implementation of diabetes ECHOs and their evaluation. Learner and patient-centered outcomes related to diabetes ECHOs are reviewed. Program implementation and evaluations have demonstrated utility of the ECHO model for diabetes programs to (1) address unmet needs of diabetes care in the primary care setting, (2) improve knowledge and confidence in managing complex diabetes and change provider prescribing habits, (3) improve patient outcomes, and (4) address diabetes quality improvement practices in primary care. More studies with broader collaboration among sites are needed to evaluate the model related to diabetes, especially applied to addressing therapeutic inertia, adoption of diabetes technology, and reducing health disparities.

Longer-term Benefits and Risks of Sodium-Glucose Cotransporter-2 Inhibitors in Type 2 Diabetes: a Systematic Review and Meta-analysis

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) are a recent class of medication approved for the treatment of type 2 diabetes (T2D). Previous meta-analyses have quantified the benefits and harms of SGLT2Is; however, these analyses have been limited to specific outcomes and comparisons and included trials of short duration. We comprehensively reviewed the longer-term benefits and harms of SGLT2Is compared to placebo or other anti-hyperglycemic medications.

METHODS

We searched PubMed, Scopus, and clinicaltrials.gov from inception to July 2019 for randomized controlled trials of minimum 52 weeks' duration that enrolled adults with T2D, compared an SGLT2I to either placebo or other anti-hyperglycemic medications, and reported at least one outcome of interest including cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events. We conducted random effects meta-analyses to provide summary estimates using weighted mean differences (MD) and pooled relative risks (RR). The study was registered a priori with PROSPERO (CRD42018090506).

RESULTS

Fifty articles describing 39 trials (vs. placebo, n = 28; vs. other anti-hyperglycemic medication, n = 12; vs. both, n = 1) and 112,128 patients were included in our analyses. Compared to placebo, SGLT2Is reduced cardiovascular risk factors (e.g., hemoglobin A1c, MD - 0.55%, 95% CI - 0.62, - 0.49), macrovascular outcomes (e.g., hospitalization for heart failure, RR 0.70, 95% CI 0.62, 0.78), and mortality (RR 0.87, 95% CI 0.80, 0.94). Compared to other anti-hyperglycemic medications, SGLT2Is reduced cardiovascular risk factors, but insufficient data existed for other outcomes. About a fourfold increased risk of genital yeast infections for both genders was observed for comparisons vs. placebo and other anti-hyperglycemic medications.

DISCUSSION

We found that SGLT2Is led to durable reductions in cardiovascular risk factors compared to both placebo and other anti-hyperglycemic medications. Reductions in macrovascular complications and mortality were only observed in comparisons with placebo, although trials comparing SGLT2Is vs. other anti-hyperglycemic medications were not designed to assess longer-term outcomes.

The Longer-Term Benefits and Harms of Glucagon-Like Peptide-1 Receptor Agonists: a Systematic Review and Meta-Analysis

BACKGROUND

Previous meta-analyses of the benefits and harms of glucagon-like peptide-1 receptor agonists (GLP1RAs) have been limited to specific outcomes and comparisons and often included short-term results. We aimed to estimate the longer-term effects of GLP1RAs on cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events in patients with type 2 diabetes, compared to placebo and other anti-hyperglycemic medications.

METHODS

We searched PubMed, Scopus, and clinicaltrials.gov (inception-July 2019) for randomized controlled trials ≥ 52 weeks' duration that compared a GLP1RA to placebo or other anti-hyperglycemic medication and included at least one outcome of interest. Outcomes included cardiovascular risk factors, microvascular and macrovascular complications, all-cause mortality, and treatment-related adverse events. We performed random effects meta-analyses to give summary estimates using weighted mean differences (MD) and pooled relative risks (RR). Risk of bias was assessed using the Cochrane Collaboration risk of bias in randomized trials tool. Quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The study was registered a priori with PROSPERO (CRD42018090506).

RESULTS

Forty-five trials with a mean duration of 1.7 years comprising 71,517 patients were included. Compared to placebo, GLP1RAs reduced cardiovascular risk factors, microvascular complications (including renal events, RR 0.85, 0.80-0.90), macrovascular complications (including stroke, RR 0.86, 0.78-0.95), and mortality (RR 0.89, 0.84-0.94). Compared to other anti-hyperglycemic medications, GLP1RAs only reduced cardiovascular risk factors. Increased gastrointestinal events causing treatment discontinuation were observed in both comparisons.

DISCUSSION

GLP1RAs reduced cardiovascular risk factors and increased gastrointestinal events compared to placebo and other anti-hyperglycemic medications. GLP1RAs also reduced MACE, stroke, renal events, and mortality in comparisons with placebo; however, analyses were inconclusive for comparisons with other anti-hyperglycemic medications. Given the high costs of GLP1RAs, the lack of long-term evidence comparing GLP1RAs to other anti-hyperglycemic medications has significant policy and clinical practice implications.

Reducing Inpatient Hypoglycemic Events: A Focus on Mealtime Insulin

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to reduce iatrogenic insulin-associated hypoglycemia at the University of Chicago Medical Center in Chicago, IL.

Updates in Gestational Diabetes Prevalence, Treatment, and Health Policy

PURPOSE OF REVIEW

Gestational diabetes (GDM) is associated with adverse pregnancy and neonatal outcomes and increased maternal risk for subsequent type 2 diabetes. The best diagnostic strategy for GDM is debated and the role of oral antidiabetic medications (OAD) for treatment is unclear. In this paper, we review methods of GDM diagnosis, updates in GDM therapy, and interventions to reduce future type 2 diabetes in women with a history of GDM.

RECENT FINDINGS

A "one-step" screening protocol for GDM using 75-g, 2-h oral glucose tolerance testing at 24-28 weeks gestation is recommended by the International Association of the Diabetes and Pregnancy Study Groups, the American Diabetes Association, and the Endocrine Society. This strategy identifies a milder degree of hyperglycemia and thus increases GDM prevalence. Studies indicate that in these cases of mild hyperglycemia, treatment decreases pregnancy and neonatal complications. Insulin analogues including detemir, aspart, and lispro have been shown to be safe in pregnancy with a pregnancy category B classification. Growing literature suggests that sulfonylureas cross the placenta and are associated with increased incidence of macrosomia and neonatal hypoglycemia. Telephone or online diabetes prevention program (DPP)-based interventions for women with GDM have shown encouraging results in pilot studies. Insurance coverage remains a barrier. Additional studies are needed to determine the safety of OAD in pregnancy. Public policy supporting DPP could help improve patient access to these proven interventions.

External Validation of the Newly Developed BETA-2 Scoring System for Pancreatic Islet Graft Function Assessment

BACKGROUND

BETA-2 score using a single fasting blood sample was developed to estimate beta-cell function after islet transplantation (ITx) and was validated internally by a high ITx volume center (Edmonton). The goal was to validate BETA-2 externally, in our center.

METHODS

Areas under receiver operating characteristic curves (AUROCs) were obtained to see if beta score or BETA-2 would better detect insulin independence and glucose intolerance.

RESULTS

We analyzed values from 48 mixed meal tolerance tests (MMTTs) in 4 ITx recipients with a long-term follow-up to 140 months (LT group) and from 54 MMTTs in 13 short-term group patients (ST group). AUROC for no need for insulin support was 0.776 (95% confidence interval [CI] 0.539-1, P = .02) and 0.922 (95% CI 0.848-0.996, P < .001) for beta score and 0.79 (95% CI 0.596-0.983, P = .003) and 0.941 (95% CI 0.86-1, P < .001) for BETA-2, in LT and ST groups, respectively, and did not differ significantly. In LT group BETA-2 score ≥ 13.03 predicted no need for insulin supplementation with sensitivity of 98%, specificity of 50%, positive predictive value (PPV) of 93%, and negative predictive value (NPV) of 75%. In ST group the optimal cutoff was ≥13.63 with sensitivity of 92% and specificity, PPV, and NPV 82% to 95%. For the detection of glucose intolerance BETA-2 cutoffs were <19.43 in LT group and <17.23 in ST group with sensitivity > 76% and specificity, PPV, and NPV > 80% in both groups.

CONCLUSION

BETA-2 score was successfully validated externally and is a practical tool allowing for frequent and reliable assessments of islet graft function based on a single fasting blood sample.

Intermittency and velocity fluctuations in hopper flows prone to clogging

We study experimentally the dynamics of granular media in a discharging hopper. In such flows, there often appears to be a critical outlet size D_{c} such that the flow never clogs for D>D_{c}. We report on the time-averaged velocity distributions, as well as temporal intermittency in the ensemble-averaged velocity of grains in a viewing window, for both D<D_{c} and D>D_{c}, near and far from the outlet. We characterize the velocity distributions by the standard deviation and the skewness of the distribution of vertical velocities. We propose a measure for intermittency based on the two-sample Kolmogorov-Smirnov D_{KS} statistic for the velocity distributions as a function of time. We find that there is no discontinuity or kink in these various measures as a function of hole size. This result supports the proposition that there is no well-defined D_{c} and that clogging is always possible. Furthermore, the intermittency time scale of the flow is set by the speed of the grains at the hopper exit. This latter finding is consistent with a model of clogging as the independent sampling for stable configurations at the exit with a rate set by the exiting grain speed [C. C. Thomas and D. J. Durian, Phys. Rev. Lett. 114, 178001 (2015)PRLTAO0031-900710.1103/PhysRevLett.114.178001].

Fraction of clogging configurations sampled by granular hopper flow

We measure the fraction F of flowing grain configurations that precede a clog, based on the average mass discharged between clogging events for various aperture geometries. By tilting the hopper, we demonstrate that F is a function of the hole area projected in the direction of the exiting grain velocity. By varying the length of slits, we demonstrate that grains clog in the same manner as if they were flowing out of a set of smaller independent circular openings. The collapsed data for F can be fit to a decay that is exponential in hole width raised to the power of the system dimensionality. This is consistent with a simple model in which individual grains near the hole have a large but constant probability to precede a clog. Such a picture implies that there is no sharp clogging transition, and that all hoppers have a nonzero probability to clog.

Dietary exposure to the endocrine disruptor tolylfluanid promotes global metabolic dysfunction in male mice

Environmental endocrine disruptors are implicated as putative contributors to the burgeoning metabolic disease epidemic. Tolylfluanid (TF) is a commonly detected fungicide in Europe, and previous in vitro and ex vivo work has identified it as a potent endocrine disruptor with the capacity to promote adipocyte differentiation and induce adipocytic insulin resistance, effects likely resulting from activation of glucocorticoid receptor signaling. The present study extends these findings to an in vivo mouse model of dietary TF exposure. After 12 weeks of consumption of a normal chow diet supplemented with 100 parts per million TF, mice exhibited increased body weight gain and an increase in total fat mass, with a specific augmentation in visceral adipose depots. This increased adipose accumulation is proposed to occur through a reduction in lipolytic and fatty acid oxidation gene expression. Dietary TF exposure induced glucose intolerance, insulin resistance, and metabolic inflexibility, while also disrupting diurnal rhythms of energy expenditure and food consumption. Adipose tissue endocrine function was also impaired with a reduction in serum adiponectin levels. Moreover, adipocytes from TF-exposed mice exhibited reduced insulin sensitivity, an effect likely mediated through a specific down-regulation of insulin receptor substrate-1 expression, mirroring effects of ex vivo TF exposure. Finally, gene set enrichment analysis revealed an increase in adipose glucocorticoid receptor signaling with TF treatment. Taken together, these findings identify TF as a novel in vivo endocrine disruptor and obesogen in mice, with dietary exposure leading to alterations in energy homeostasis that recapitulate many features of the metabolic syndrome.

Update on diabetes classification

This article highlights the difficulties in creating a definitive classification of diabetes mellitus in the absence of a complete understanding of the pathogenesis of the major forms. This brief review shows the evolving nature of the classification of diabetes mellitus. No classification scheme is ideal, and all have some overlap and inconsistencies. The only diabetes in which it is possible to accurately diagnose by DNA sequencing, monogenic diabetes, remains undiagnosed in more than 90% of the individuals who have diabetes caused by one of the known gene mutations. The point of classification, or taxonomy, of disease, should be to give insight into both pathogenesis and treatment. It remains a source of frustration that all schemes of diabetes mellitus continue to fall short of this goal.

Geometry dependence of the clogging transition in tilted hoppers

We report the effects of system geometry on the clogging of granular material flowing out of flat-bottomed hoppers with variable aperture size D and with variable angle θ of tilt of the hopper away from horizontal. In general, larger tilt angles make the system more susceptible to clogging. To quantify this effect for a given θ, we measure the distribution of mass discharged between clogging events as a function of aperture size and extrapolate to the critical size at which the average mass diverges. By repeating for different angles, we map out a clogging phase diagram as a function of D and θ that demarcates the regimes of free flow (large D, small θ) and clogging (small D, large θ). We do this for both circular holes and long rectangular slits. Additionally, we measure four types of grain: smooth spheres (glass beads), compact angular grains (beach sand), disklike grains (lentils), and rodlike grains (rice). For circular apertures, the clogging phase diagram is found to be the same for all grain types. For narrow slit apertures and compact grains, the shape is also the same as for circular holes when expressed in terms of projected area of the aperture against the average flow direction. For lentils and rice discharged from slits, the behavior differs and may be due to alignment between grain and slit axes.

Elastic instabilities of polymer solutions in cross-channel flow

When polymer molecules pass near the hyperbolic point of a microchannel cross flow, they are strongly stretched. As the strain rate is varied at low Reynolds number (< 10(-2)), tracer and particle-tracking experiments show that molecular stretching produces two flow instabilities: one in which the velocity field becomes strongly asymmetric, and a second in which it fluctuates nonperiodically in time. The flow is strongly perturbed even far from the region of instability, and this phenomenon can be used to produce mixing.

Crystal structure of the phosphatidylinositol 3,4-bisphosphate-binding pleckstrin homology (PH) domain of tandem PH-domain-containing protein 1 (TAPP1): molecular basis of lipid specificity

Phosphatidylinositol 3,4,5-trisphosphate [PtdIns(3,4,5)P(3)] and its immediate breakdown product PtdIns(3,4)P(2) function as second messengers in growth factor- and insulin-induced signalling pathways. One of the ways that these 3-phosphoinositides are known to regulate downstream signalling events is by attracting proteins that possess specific PtdIns-binding pleckstrin homology (PH) domains to the plasma membrane. Many of these proteins, such as protein kinase B, phosphoinositide-dependent kinase 1 and the dual adaptor for phosphotyrosine and 3-phosphoinositides (DAPP1) interact with both PtdIns(3,4,5)P(3) and PtdIns(3,4)P(2) with similar affinity. Recently, a new PH-domain-containing protein, termed tandem PH-domain-containing protein (TAPP) 1, was described which is the first protein reported to bind PtdIns(3,4)P(2) specifically. Here we describe the crystal structure of the PtdIns(3,4)P(2)-binding PH domain of TAPP1 at 1.4 A (1 A=0.1 nm) resolution in complex with an ordered citrate molecule. The structure is similar to the known structure of the PH domain of DAPP1 around the D-3 and D-4 inositol-phosphate-binding sites. However, a glycine residue adjacent to the D-5 inositol-phosphate-binding site in DAPP1 is substituted for a larger alanine residue in TAPP1, which also induces a conformational change in the neighbouring residues. We show that mutation of this glycine to alanine in DAPP1 converts DAPP1 into a TAPP1-like PH domain that only interacts with PtdIns(3,4)P(2), whereas the alanine to glycine mutation in TAPP1 permits the TAPP1 PH domain to interact with PtdIns(3,4,5)P(3).

Caries detection accuracy by multiple clinicians and techniques

This study compared caries detection by multiple clinicians with the accuracy of detection with Caries Detector dye. Four clinicians rated the extent of caries on 100 extracted teeth. After dye application, visual assessment of residual dye was recorded for each specimen. This was repeated after the teeth were embedded in epoxy resin and sectioned. The results indicate that although reasonably accurate overall, clinicians often disagree whether caries is present. The use of a caries detector solution may be a valuable adjunct tool to correct caries diagnosis.

Investment strength as a function of time and temperature

OBJECTIVES

The purpose of this investigation was to evaluate and compare the compressive strength characteristics of selected investments and to determine if these change as a function of time and temperature after mixing.

METHODS

Two phosphate-bonded investments and one gypsum-bonded investment were selected and 288 cylindrical specimens were fabricated (n = 9). Baseline compressive strength values were determined for each material at room temperature and compressive strength measurements were made for all materials at 700 degrees C, and at 872 degrees C only for phosphate-bonded investments. Each material was tested at 2, 6, 12, and 24 h after mixing. Specimens were heated at 15 degrees C/min and heat soaked for 5 min in a burnout oven at the applicable testing temperature. They were transferred to a preheated chamber on an Instron testing machine and subjected to a compressive load at a crosshead speed of 2 mm/min until failure. The resulting strength data are presented in MN/m2.

RESULTS

The gypsum-bonded investment did not exhibit marked differences in strength as a function of either time or temperature. The phosphate-bonded investments, on the other hand, demonstrated considerable changes in compressive strength and differed in compressive strength characteristics at 700 degrees C and 872 degrees C respectively.

CONCLUSIONS

At elevated temperatures, all materials approximated peak strength 2 h after initial mixing. At room temperature, the phosphate-bonded investments in this study were not significantly stronger than the gypsum-bonded investment material. However, they exhibited increased compressive strength as a function of time and temperature that was considerably higher than that exhibited by the gypsum-bonded investments.

Meeting the challenge of consultation and collaboration: developing interactive teams

The roles of special educators as consultants and collaborators have long been established and supported. The rationale for these roles is also well documented. Many models--consultative, collaborative, and teaming--have been suggested in the literature; sometimes, these models exhibit similar goals, competencies, and processes. Because of intensified pressures to collaborate, successful implementation of collaborative and team efforts requires that special educators expand their roles as interactive professionals. The purpose of this article is to define and describe the consultation, collaboration, and teaming models that have been implemented, discuss their strengths and limitations, delineate how these models contribute to interactive teaming, outline key features of the interactive team, and provide some guiding principles for successful implementation.

Detection of medullary carcinoma of the thyroid with I-131 MIBG

Imaging with I-131 MIBG has proved useful for the detection of pheochromocytoma, neuroblastoma, and other neoplasms of neural crest origin. The authors present a case of a patient who was initially diagnosed as having follicular carcinoma of the thyroid in which I-131 MIBG played a key role in leading to the diagnosis of medullary carcinoma of the thyroid. Local and distant metastases were detected using I-131 MIBG imaging. Uptake of I-131 MIBG by medullary carcinoma of the thyroid has both diagnostic and therapeutic implications.

A survey of trainees and recently accredited specialists in occupational medicine in the United Kingdom

Information from a study group of doctors training or recently trained in occupational medicine was gathered using a self-administered questionnaire mailed to each subject's registered address. Of the 224 individuals identified from scrutiny of records held by the Faculty of Occupational Medicine, replies were received from 181 (81 per cent). Recruitment occurs in broadly equal proportions from general practice, general practice trainees, the hospital sector and the forces, with a wide diversity of experience among trainees. On average, trainees experience at least two industrial sectors during their training. There were disappointingly small numbers in part-time training.

Studies on osteoporosis. II. Effect of estrogens and fluoride on experimental osteoporosis. A preliminary report

Total skeletal calcium level was determined in female mice with the aid of whole body neutron activation analysis. Three months treatment with heparin produced significant osteoporosis in C3H/St(Ha) mice of 3--5 months of age. Treatment with a conjugated natural estrogen preparation (Premarin) prevented this phenomenon but high level fluoride in the drinking water failed to show preventive activity.

Studies on osteoporosis I. Experimental models. Effect of age, sex, genetic background, diet, steroid and heparin treatment on calcium metabolism of mice

C3H/St(Ha) and C57Bl/6(J) mice of both sexes and various ages were exposed to whole body neutron irradiation. The 49Ca generated (half life 8.8 minutes) was immediately determined in a whole body counter. Total body calcium content was calculated. It was assumed that 99% of this represented skeletal calcium. In females, significant decrease in calcium content occurred after 23 months of age. In C3H/St(Ha) mice, low calcium diet, heparin (500 i.u./Kg. b.i.d.) and prednisolone (50 mg/Kg) treatment accelerated calcium loss and produced significant decrease in 3 months. C57Bl/6(J) mice were less susceptible to the latter drugs.

Metastasizing basal cell carcinoma of the skin with myelophthisic anemia

A case report of a metastasizing basal cell carcinoma is presented, primary in the leg with regional inguinal lymph node metastasis, followed by extensive metastasis to skin and bone marrow with myelophthisic anemia and terminal splenohepatic and unilateral adrenal metastasis.